1. Powell, Suzanne K. RN, MBA, CCM, CPHQ


Ethical issues and dilemmas span from conception to the grave. The interconnectedness of advocacy, ethics, and end of life/death with dignity are woven into this issue of the Professional Case Management journal. Case management is a critical member of the team when these discussions arise. And knowledge of the issues, along with legal, ethical, and professional codes, is highlighted.


Article Content

Ethical issues shift as society, technology, and professional practice patterns change. Step back in time to 1950. Few of the prominent ethical issues of today were discussed: abortion, euthanasia (doctor-assisted suicide), genetic experimentation, or rationing of healthcare. At the time genetic research was not far enough advanced to cause major concern, and healthcare was basic enough-with little high-tech equipment-to be affordable. The 1950 American Nurses Association (ANA) code stated that a nurse's obligation was to carry out the physician's order and to protect the physician's reputation. This code left little motivation for a nurse to assess an ethical dilemma.... - (Powell, 1996, p. 169)


This was an excerpt from my first book on case management, written in the mid-1990s about the 1950s. Many of the 1990s ethical issues are still pertinent today: withholding/withdrawing of care, rationing of health care (a headliner just last week in 2016), choice of who gets precious organs for transplantation, patient preferences versus self-determination, or futility of care. But ethical issues have certainly evolved ... and this is what the July/August 2016 Professional Case Management (PCM) journal is all about.


The rapid advancement of technology has not only caused true help in health care but also carved out new ethical dilemmas-some of which are currently evolving. A few of the recent headliners include:


* DNA/genetic and stem cell advances, modifying human embryos ("editing" embryos or "cut and pasting" genetic material)


* digital pill (you take it, your doctor knows you took it, or vice versa)


* high cost of medications (and rationing those medications)


* physician-assisted suicide


* The future ability of three-dimensional (3D) printers to build/replace human organs


What? 3D printing technology for replacement organs? I haven't even gotten used to the "personal pig" idea, which I first heard about in the 1990s (and porcine heart valves have been around for decades). But in a sense, that concept is still a reality. According to a study published in October 2015, scientists are one step closer to using animals as organ donors for humans in need. Although the study did not demonstrate safe organs, it showcased a new gene-editing technique that brings us closer to the "animal to human transplant" trajectory by removing harmful retrovirus.


The researchers used a gene editing technique called CRISPR-Cas9 (more commonly referred to as CRISPR). CRISPR uses the natural defense mechanisms of bacteria to target specific pieces of DNA in a genome, allowing scientists to essentially crop out-and potentially replace-individual sequences. (Feltman, 2015, p. 1)


The Personal Pig story may be a little humorous (even silly today), but few things are more deeply serious than the completion of someone's end-of-life (EOL) wishes. As case managers, we will be in situations where EOL discussions will be the most important "task" of the day. And these may come up as work-related or personal stories. I have two personal ones where the wishes were not adhered to. One was the husband who died in the hospital (no autopsy was legally required). The wife did not believe in autopsies, yet one was done. I was there when she was told about it; I will never forget the cry of anguish (and this happened over 35 years ago).


A second one-also in the 1970s-was a favorite uncle. He put his wishes on a cassette tape. It was months after his sudden death that the family listened to this. Months followed where they considered exhuming the body to give him his final wishes; it was heart-wrenching for the family. It still haunts his daughter to this day.


This issue has much about the topic of Ethics. The premise for the article, "Essentials in Advocacy Revisited," was first written in this journal in 2005. Even though I had deemed it a "classic" among manuscripts, Dr Tahan has graciously updated it. And the update warranted a two-part article.


"The Evolution of End-of-Life Care: Ethical Implications for Case Management," by Fink-Samnik, is another thoughtful and timely article in this issue, demonstrating the evolution of the death-with-dignity movement and the legislation and ethical implications that connect with these topics.


"Case Management Ethics: High Professional Standards for Health Care's Interconnected World," by Sminkey and LeDoux, discusses the codes of professional conduct and the two worlds case managers live in.


New guidelines for continuing education units (CEUs) in many case management certifications and licensures require ethics-related CEUs. There is both opportunity and knowledge in this issue of the PCM journal. I have said in previous texts that there is no answer at the back of a book on ethics. It is a process where all the impacted people must get together and make the best choice(s) possible, with the given circumstances. Technology isn't good or bad. And it isn't the knowledge we have, but what we do with the knowledge that catapults it into the "ethical" realm. Therein lies the criticality of case management when we assist in these cases.




Feltman R. (2015, October 13). Gene editing could make pig-to-human organ transplants a reality. Retrieved April 3, 2016, from[Context Link]


Powell S. P. (1996). Nursing case management: A practical guide to success in managed care. Philadelphia, PA: Lippincott-Raven. [Context Link]


advocacy; case management; death with dignity; end of life; ethics; professional codes