ABSTRACT
In rehabilitation, the value that patients place on particular goals is considered a central concern. Patients often are in positions of disempowerment, and one of the objectives of intervention is usually to maximize their level of control over their lives. Patient involvement in goal setting is viewed as one of the main ways that health professionals can share control over clinical decision making with their clients, thus beginning their journey towards greater independence (Baird, Tempest, & Warland, 2010; Blackmer, 2000). However, a number of factors can complicate the process of involving patients in goal setting, and it is not always easy to determine the most ethical approach for individual people. It would be comforting if we, as health professionals, could simply decide that the goals of rehabilitation should be whatever patients wished to work towards, regardless of the context of the clinical situation, but such a perspective greatly oversimplifies the complexities of work in the real world of rehabilitation. Furthermore, challenges around maximizing patient autonomy are not the only ethical issues relevant to goal setting in rehabilitation – far from it. Consider the following:
CONTENTS
4.1 Introduction .......................................................................................................................... 67 4.2 What Is Ethics? .....................................................................................................................68 4.3 Why No Ethical Algorithm? ............................................................................................... 69 4.4 What Is Principlism? ........................................................................................................... 71 4.5 What Is Value Pluralism? .................................................................................................... 73 4.6 Examining the Principles ................................................................................................... 74
4.6.1 Autonomy ................................................................................................................. 74 4.6.2 Beneficence and Non-Maleficence ......................................................................... 76 4.6.3 Justice ......................................................................................................................... 79
4.7 Addressing Criticisms of Principlism ............................................................................... 82 4.8 Ethics of Goal Setting versus Ethics in Goal Setting ......................................................83 4.9 Conclusion ............................................................................................................................85 References .......................................................................................................................................86
This is only one of many possible scenarios where aspects of goal setting ideology (in this case, that of setting objectives for rehabilitation which are meaningful and valued by the patient) can conflict with other apparent moral responsibilities. In this chapter, goal setting is considered from the perspective of bioethics. As will emerge, in common with nearly all other areas of health-care provision, rehabilitation is rife with such ethical challenges. But we had better say from the outset that this chapter will not provide you with any algorithm for resolving these ethical difficulties. Its aim is more modest, but also more realistic: to provide the reader with a richer way of appreciating, discussing and perhaps finding a way through the ethical issues that the practice of goal setting in rehabilitation throws up.
