What are some of the ethical principles

103 6 Ethical principles The atrocities committed by members of the medical professions during the Second World War in Germany, Russia, the USA, Japan and other parts of the world shocked the world. As a result, from the middle of the 20th century in health care and education there was an increased reflection on the ethical and moral basis of action and on the basic attitudes of professionals towards the people entrusted to them. At the same time, with medical progress and the associated economic interests, this discussion has also become more complex. Which basis was there broad approval? Giovanni Maio proclaims in his standard work on medical ethics, Focus on Man, "that even in the value-plural world one can name principles on which one can agree based on the different theories of value justification" (Maio, 2012, p. 120). It refers to the principles: medium range, which we already outlined in the second chapter. From this, models of ethical procedure can be designed that combine the concrete individual case (casuistry) with ethical theory. This takes place in an intensive discourse, in the systematic technical discussion of all those involved with the respective question (see Chapters 2.5 and 2.6). In 1977 Beauchamp and Childress published their book Principles of Biomedical Ethics, which appeared in its seventh edition in 2013 and is considered to be very influential overall (Beauchamp & Childress, 2013). They worked out four ethical and moral principles of medium range as the basis of ethical thinking in health care - respect for autonomy, non-harm, care, justice - which are partly based on the basic principles already found in Hippocrates - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 104 6 Ethical principles (see Section 5.1), sometimes go beyond them. These principles are widely accepted, in fact they are actually immediately obvious to everyone due to a common morality and should therefore also occupy a central position in this book. Their "self-evidence" also means a difficulty: even if the principles have a medium range and are not as abstract as the categorical imperative according to Kant, they are nevertheless principles, i.e. general principles that are always interpreted in relation to the specific case Need to become. They do not name specific instructions for action. Perhaps one can recall the origin of the word principle from the Latin principium (= beginning, origin). In this way, the four principles can be understood as starting perspectives for solving problems in concrete ethical questions. Often you will also notice that the principles conflict with one another (ethical dilemma), so that they cannot be followed absolutely. This is the case, for example, when - after careful consideration - for reasons of caring for a patient, his or her autonomy is temporarily restricted (e.g. the restraint of a patient who is self-harming or harming others in psychiatry). It should be noted, however, that these four principles were developed in a “biomedical” context. How far do they cover the problems that arise in music therapy practice, teaching and research? Are there not other principles of medium scope of fundamental importance, such as those formulated by Dileo (2000, p. 7f.) As core ethical principles? It also names: honesty, reliability (fidelity), honesty, credibility (veracity), recognition of the dignity of the individual (acknowledging dignity), caring and committed action (acting with caring and compassion), striving for the best possible competence (striving for excellence), Accountability and Integrity. Should further ethical attitudes (variety of reasons) be considered at all? Nida-Rümelin (n.d.) suggests the following categories of reasons for action: obligations, duties, demands, freedoms, solidarity and benevolence, self-interest and principles of invariance. We use the above four Beauchamp and Childress principles as a starting point, as a possible thinking model, without claiming that there are no other essential principles or 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 105 6.1 could give autonomy that can claim similar importance. We should be open to other relevant principles and ethical attitudes. 6.1 Autonomy In our time (and at least in our German-speaking cultural context), respect for autonomy, for the right of the individual to be able to freely determine his or her life (self-determination) has become a self-evident basic ethical attitude in living together (self-determination). Yes, you can hardly imagine that it was any different. And yet it was not so long ago that extensive medical research on humans did not require the express consent of those affected or that medical research on children did not require permission (see above). In contrast, today (for example in music therapy) it is not even possible to take a photograph or video recording at work without obtaining express permission beforehand (see Chapter 11). Music therapists need the informed consent of their patients for all interventions with patients, by no means only for research. This means that they have to give the patients comprehensive information to enable them to decide for themselves about their therapy. The patient (or, in the case of minors, their parents) sets the treatment contract and determines the therapy goals, the therapists act as experts and mediators of the goals. As a rule, the autonomy of patients must be respected, even if decisions - from the perspective of the treating person - may appear incomprehensible or even wrong. Semantically, the word autonomy comes from the Greek autos nomos, self-legislation. But what actually is autonomy? For Waldschmidt (2003) the (post) modern concept of autonomy is a fruit of the philosophical discourse of the Enlightenment. Immanuel Kant had shown in the 19th century that humans are fundamentally capable of self-determination because they have practical reason. Reason makes people a rationally acting subject who is not at the mercy of their needs and emotions, but can decide with caution. Due to the property of reason 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 106 6 Ethical principles are also everyone Human beings are an "end in themselves" (or "end in itself," as Kant puts it) and therefore - in contrast to "things" - must not just become a "means to an end" for others.4 People deserve respect and appreciation because their nature already distinguishes them as an end in themselves, that is, something that must not be used merely as a means, and therefore as far as it restricts all arbitrariness (and is an object of respect). (Kant, 1785, second section) A reason-based concept of autonomy does not help if people have only limited rational abilities due to illness or developmental restrictions. To what extent do the "unreasonable" also have a right to self-determination? What happens when people cannot be asked about their wishes without further ado or may even understand the questions but cannot answer (ability to consent)? This group of people can include people with apallic syndrome, with dementia changes, with severe psychiatric illnesses, but also people with intellectual disabilities. While a few decades ago it was taken for granted that decision-making authority in such cases would largely be transferred to the support system, the right to self-determination is now widely regarded as a "disability policy paradigm" (cf. Waldschmidt, 2003, 2012). Since the 1960s, a critical attitude towards paternalistic attitudes and structures within medicine has developed in Central Europe, which was largely initiated by those affected (paternalism). The medical profession as "demigods in white" was questioned, demands were made for self-determination and informed consent of the "responsible patients" for all medical interventions. The anti-psychiatric movement was also influential here, and under various names it initiated a reform of psychiatry as a science and institution (see the review article by Goddemeier, 2014). 4 "[...] man and in general every rational being exists as an end in itself, not just as a means for arbitrary use for this or that will [...]" (Kant, 1785, second section). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 107 6.1 Autonomy And what is the self-determination of "underage" To assess children and adolescents in therapy? Do not children also have a (certain) right to self-determination, as is enshrined as a fundamental right in the constitutions (e.g. in Article 2 of the German Basic Law or in the UN Convention on the Rights of the Child) (see also the explanations in Chapter 11 )? Children are also to be informed about the therapeutic measures in an age-appropriate manner. You can possibly gain a (certain) insight into this in order to give your approval or disapproval. In principle, they are to be granted a right of self-determination - according to their ability to understand. In the event of insufficient insight, which must be carefully assessed by the medical or therapeutic side and by the legal guardian, the child's right to self-determination with regard to therapeutic measures and participation in research projects is exercised by the parents or their legal representative (see Michael , 2011, p. 115ff.). It becomes more complicated when the insights gained (e.g. from the child, parents, therapist) are different or are assessed differently. Case study 6.1: My little girl Ms. Z. (40), with the diagnosis of trisomy 21, becomes more courageous in the course of the music therapy group, more eager to experiment, shows a sense of humor, and can increasingly get involved in the therapy. Therapy goals: Promotion of self-perception, the ability for dialogical exchange, the ability to be autonomous. Ms. Z. begins to allow and enjoy age-appropriate exchanges. After six months, the music therapy is ended at the request of the mother, who - as she says - "wants to keep her little girl". Regular discussions with parents are usual for therapies with children and adolescents. The parents of people with disabilities should also be spoken to regularly - at least if they are the clients of the therapy - in order to minimize possible discrepancies in the objectives of the therapy. On these occasions the music therapist can carefully promote a view that supports a growing degree of self-determination on the part of the client. At the same time, it should be borne in mind that a 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 108 6 Ethical principles do not change the attitude of those responsible quickly and approval may not always be achieved. Another example shows doubts at the beginning of music therapy: Case study 6.2: Sensitivity to noise An acutely highly depressed patient suffers from sensitivity to noise in his illness phase. He describes how even music torments him at the moment. At the moment he could only take rest. Participation in the music therapy was ordered by a doctor, the patient has no opportunity to refuse participation in a therapeutic offer within the framework of inpatient treatment. At first it seems quite natural that the "responsible patient" can refuse music therapy. Why should he have "no opportunity" to refuse the medically prescribed therapy? The clarification of this question is only partly the responsibility of the music therapist, because it primarily affects the relationship between the patient and the person responsible for the case. But maybe it's not about the patient having to completely reject music therapy in the example. Perhaps his approval for the attempt to carefully explore the sensitivity to noise can be obtained after all. He could be assured that no music would be heard without his consent; that rather the »silence« and the ambient noises can be explored, also with the question of how the patient can set up in an acoustic environment that is tolerable for him if possible. But he definitely has the power to decide whether and which sounds are also produced in music therapy. The question could also arise whether the music therapist in the above example feels free to include sound and music according to the situation. Does she perhaps feel pressured to use music for the most part in music therapy? If so, from whom? What principles and assumptions has she internalized for this? What ideas and expectations are there in this question in the collegial environment of the clinic? That would then be a question that concerns the autonomy of the music therapist and thus her self-reflection. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 109 6.2 Non-damage 6.2 Non-damage case study 6.3: Raise your voice A shared apartment for mentally handicapped people would like to offer some of its clients group music therapy. The supervisors select clients who are allowed to participate. After a few weeks of music therapy, a client always begins to vocalize more strongly after the music therapy lesson, becomes more restless and seems to need more attention in the group. There are different opinions on this phenomenon in the care team: First: The client demands more relationship and contact through the increased use of his voice. Second: The music therapy would tense the client more, so it would ultimately harm him and he would have no way of bringing about a change or an end to this offer. According to Beauchamp and Childress (2013), non-harm initially means: One should not cause harm or harm to anyone. As with the other principles, this statement, as clear as it appears at first sight, requires interpretation. Above all, it is to be examined for the specific situation. How do we "harm" a person? And what kind of possible "damage" is relevant to our context? Any violation of a person's limits of autonomy can already be viewed as harm. The infliction of pain, the actualization of painful feelings - they are often inevitable in medicine and psychotherapy. Maio explains the duty to avoid harm as follows: »To harm the other means not to see people as an end in themselves and to violate their rights. Therefore, the principle of no harm is ultimately based on the recognition of the fundamental rights of the other ”(Maio, 2012, p. 124). Without a more detailed description of the concept of damage, this obligation is difficult to comply with. Damage can be derived from the rights that are violated in each case. These rights can be, for example: ➣ the right to self-determination ➣ the right to physical integrity ➣ the right to psychological integrity (Maio, 2012, p. 124, according to Katz, 1972) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 110 6 Ethical principles Maio draws the boundaries of the non-harm principle for the field of medical ethics much narrower: than »the obligation of Medicine, of its own accord, not to harm the sick person ”(Maio, 2012, p. 125). This can also apply to the fields of music therapy. For music therapists, the no-harm principle means not to harm the client on their own initiative! In the example given above, however, that is precisely the question: Does music therapy harm the client more than it does him or her? On closer inspection, we get the impression that the main motivation for this question arises from the team's attitude of caring for the client. It is asked whether the client cannot cope with and integrate the emotional movements that arise in music therapy in such a way that they lead to development and growth, but on the contrary cause overstimulation or excessive demands, which then lead to withdrawal, isolation, etc. .The question is therefore less directed towards the damage that music therapy would directly cause, but rather towards the question of the dosage, the adequacy of the offer in relation to the client's currently available coping options. This is a question more related to our "duty of care," which is discussed in the next section. Disregard of the duty of care can then very well lead to damage for the client - for example to a violation of his right to psychological integrity. At the same time, questions about the principle of autonomy arise here: Is it possible to follow the client's declaration of will even if they are not doing themselves well with their actions or are even harming themselves? To put it bluntly: Doesn't the basic right of autonomy also include the right to harm oneself (within certain limits)? 6.3 Care Case study 6.4: “I'm staying!” A music therapist writes: “In the oncological palliative care unit of a hospital, I enter the room of a patient with advanced cancer. While I was still introducing myself, the patient, who was clearly doing badly, said in a weak voice that she didn't want anything. Nevertheless, I pull up a chair, sit down by her bed and do nothing ... and 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 111 6.3 Caring think: Just because she is feeling bad, I'm there. She doesn't even know what she's missing out on. Due to external framework agreements, there would only be another chance for contact three days later. She won't get rid of me that quickly. I'm staying! ”In this example, already known from Chapter 2, we immediately recognize an ethical conflict situation: the therapist makes an offer of support, the patient declines. We have to assume that she has reasons for refusing the help. Perhaps she rejects "music therapy" out of ignorance or because she associates something with it that does not seem appropriate or helpful to her at the moment. Perhaps she is so busy trying to stabilize herself in her current situation that she cannot imagine any support or interference from outside. Or she just needs to be to herself. All of this would be contrary to the offer of the therapist. From the point of view of the principle of autonomy, the matter would quickly become clear: the patient alone decides on the therapeutic interventions that take place with her! But again, it's not that simple. At the same time, the therapist has an ethical duty to help "professionally" (duty of care). And she has technically justified suspicions that (in the patient's sense!) It could be better to stick with the music therapy support offered. Aspects such as relief, relaxation, information or distraction play a role here. Case study 6.5: No music! A 30-year-old man suffering from paranoid-catatonic schizophrenia is housed in a highly secured forensic psychiatric clinic. It shows severe formal thought disorders as well as hallucinations in various sensory areas. Due to his very aggressive behavior, he is fixed to his bed with a belt. Twice a week, he is offered receptive music therapy for half an hour. During the initial period of music therapy, the patient yells "No music!" When the music therapist enters the room. The music therapist decides to continue the session. He is sitting on a chair in the corner of the room and playing music. After a while, the patient relaxes a little. Sometimes he becomes a little clearer in speech and thoughts, or he sings and makes short, relevant comments about the music. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 112 6 Ethical principles Certainly there is no clear answer here either whether it is legitimate to start the music therapy intervention against the will of the client. Such an action remains contradictory (just as therapeutic treatment under the conditions of coercive measures is inherently highly contradictory). In any case, thorough reflection, strong arguments and particular sensitivity are required when therapists (initially) oppose the autonomous expression of will of patients. What is actually meant by the principle of care? This can be paraphrased and broken down as follows (after Beauchamp and Childress, quoted in Maio, 2012, p. 127): ➣ One should prevent evil and harm. ➣ One should eliminate evil and harm. ➣ One should do good and promote good. Reflecting on the concept of care is also difficult because the core of the therapeutic profession is geared towards providing assistance and support. The commandment to do good and promote good seems to be a matter of course - and as such is particularly worthy of reflection! In case study 6.5 it would first have to be questioned whether it was really primarily about trying to prevent or reduce harm and harm for the patient. What else could play a role? Perhaps the therapist's offense or annoyance at a rejection? Uncertainty? Injured pride? For therapists working on a fee basis: threatened loss of income? The endangered reputation in the team? From the point of view of the principle of care, only considerations relating to the improvement of the patient's situation are relevant. These are to be compared and weighed up against the possible violation of autonomy. Without this consideration, the risk of paternalistic action would be even greater than it already is ("I know better than you what is good for you!"). In other words: Without a careful (self-) examination we would be dealing with an interaction that manifests the asymmetry in the therapist-patient relationship, disregards the patients as independent administrators of themselves, perhaps even functionalizing them by making them available for others Purposes and goals of the therapist are used. Against the background of such considerations and a critical questioning, the therapists could use 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 113 6.4 Fairness The option chosen to stay in the room first was an appropriate decision. However, it might have been just as appropriate to follow the patient and come back at another time or day. This decision cannot be made in principle, it has to be made in the situation itself. We recognize another characteristic of the law of care that Maio points out: The law of care is - in contrast to the command not to harm patients, for example - a "soft" commandment, not a compulsory obligation. The requirement of care becomes mandatory as an obligation to provide assistance, but under the conditions that the life and health of patients are acutely endangered. In such a situation, the obligation to save a human life also gives rise to a legal obligation (cf., for example, on failure to provide assistance in German law §323c StGB). 6.4 Justice Case Study 6.6: Music Therapy Assessment One task of music therapists in Neuroreha is to check the contact functions of a patient diagnosed with »hypoxic brain damage«. How long the patient is treated in the rehab department may depend on the result of your assessment. The specialized music therapy methods for making contact and for interacting with patients, whose contact options can be severely impaired due to brain damage, often lead to music therapists being asked for their professional assessment. Can contact functions be observed with some certainty in patients or not? Can these observations also be understood by other people? The transfer of patients, for example, may depend on the assessment, since those patients who are not able to establish contact after a certain period of treatment are usually transferred from the rehabilitation clinic to a nursing home. When asked for a professional opinion, music therapists are therefore often unexpectedly confronted with conflicts of interest: While relatives of the patients may wish to continue intensive care in the clinic - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 114 6 Applying ethical principles (in order to be able to hope for a significant improvement in the state of health) is one of the tasks of the employees of the clinic or the cost bearer to control the treatment costs of the highly specialized and expensive therapy, possibly to limit them - and to ask the question of the efficiency of the measures. In this example there are several aspects that can be discussed from the point of view of equity. Even if it may at first seem easy or self-evident to generally agree on a principle such as justice, on closer inspection it becomes apparent that there are different standpoints and concepts with regard to the desired justice. There is no such thing as justice. It is therefore first necessary to clarify what the prevailing concept of justice of the participants is and from which perspectives the situation is interpreted. Under the stipulation that it is about the fair distribution of scarce goods, which should also play a role in the vignette, Maio (2012, pp. 130ff.) Explains four different models of justice that are briefly summarized here. They each emphasize different aspects of striving for justice - and each raise different questions: ➣ The equality model (egalitarianism) particularly emphasizes the equality of people: everyone must have the same opportunities for optimal treatment, regardless of economic conditions. But how can equality be established when every situation is different from the other? ➣ The model of freedom (liberalism) proclaims that every person is responsible for providing security in the event of illness. The economic situation of the patients determines which treatment they receive - what they can afford. The model on which the private health insurance funds are based only works in combination with an existing basic health care system. Otherwise it would reach its limits at the latest for people with chronic illnesses or permanent restrictions. ➣ The efficiency model strives for an optimized relationship between benefits and costs. The main orientation of the assessment towards the consequences and benefits of interventions makes this model appear related to utilitarian thinking (see glossary: ​​utilitarianism). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 115 6.4 Justice ➣ Finally, the fairness model asks about the neediness of the Individuals and proclaims the priority of allocation for those who are worst off - even if there is a loss of efficiency, freedom and equality. You can gain something directly from each of these models. Neither seems completely absurd, each seems partially justified and necessary. The respective contexts of a situation and the people involved are likely to determine which aspects come to the fore. While the demand for efficiency is increasingly prevalent in the health care system, often in connection with (market-liberal) demands for individualized (i.e. not collective) protection against health risks, the equality and fairness model should spontaneously be closer to the experience of those affected and their relatives, because it seems to take greater account of the individual in his or her current plight. The therapeutic and nursing staff have good access to the interests of the patients and their relatives through their proximity to the patients and through the sensitive contact associated with their work; as employees of an institution that works according to economic aspects, however, the aspect of efficiency should not be entirely alien to them. The music therapist in the vignette must therefore - in addition to his as independent and professional assessment of the contact functions as possible - include the existing evaluation contexts and deal with them. This will be best possible if he not only has to give his opinion "in isolation", but thinks and advises together with the other participants about the assessment, its significance and its possible consequences. Case study 6.7: Persuasion in the meeting When, in a case discussion with my colleagues in the Physiotherapy and Speech Therapy departments, the decision was made as to whether I, as a music therapist, would take care of a young man (early 20s, syndrome of unresponsive wakefulness after attempted suicide), we received Feedback from the attending physician that this would probably make little sense, as there were no measurable reactions from the patient in question. This encountered incomprehension both with me as a music therapist and with the two colleagues. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 116 6 Ethical principles and concern. However, through discussions and “persuasion”, the music therapy was approved - with great success. The best way to find “just” solutions to ethical conflicts is to try to combine several models and weigh them against one another. Weiss Roberts emphasizes that the principle of justice is not only to be applied to the social level, but that it also affects, for example, power relations at the individual level: “The principle of justice brings equitable distribution of power and resources into ethical focus. On an individual level, the tensions between beneficience and autonomy assume a locus of decision making somewhere between the physician and patient "(Weiss Roberts, 2016, p. 9). References Beauchamp, T. L. & Childress, J. F. (2013). Principles of biomedical ethics. 7th edition New York: OUP. Dileo, C. (2000). Ethical thinking in music therapy. Cherry Hill: Jeffrey Books. Goddemeier, C. (2014). "Antipsychiatry" movement: An institution is in the pillory. Deutsches Ärzteblatt International, 13 (11), 502. Kant, I. (1785). Basis on the metaphysics of ethics. Available at https: // gutenberg. spiegel.de/buch/grundlege-zur-methaphysik-der-sitten-3510/1 Katz, J. (1972). Experimentation with human beings. New York: Russel Sage. Maio, G. (2012). Focus on people: ethics in medicine. Stuttgart: Schattauer. Michael, N. (2011). Research on Minors: Constitutional Limits. Constitutional Limits. Berlin: Springer. Nida-Rümelin, J. (undated). Philosophy. Introduction to Practical Philosophy [book accompanying the ZEIT Academy DVD of the same name]. Hamburg: Zeitverlag Gerd Bucerius. Waldschmidt, A. (2003). Self-determination as a disability policy paradigm - perspectives of disability studies. From politics and contemporary history. http: // www. bpb.de/apuz/27792/selbstbestetzung-als-behindertenpolitisches-paradigmaperspektiven-der-disability-studies Waldschmidt, A. (2012). Self-determination as a construction: everyday theories of disabled women and men. 2., corr. Aufl. Wiesbaden: VS Verlag. Weiss Roberts, L. (2016). A clinical guide to psychiatric ethics. Arlington: American Psychiatric Association Publishing. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38