Ethics Resources

The Ethics Center has identified a variety of educational resources about ethical practices in health care for individuals who are new to the field as well as those who are more experienced.

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Shared Decision Making with Patients

Decision-making capacity
Informed consent process
Surrogate decision making
Advance care planning
Limits to patient choice
Other

Overview
IntegratedEthics Online Learning Module: Shared Decision Making with Patients

Goals of Care in the ICU: Palliative Care at the End of Life (IN fOCUS January 2005) [PDF]

1.a Decision-making capacity [ability of the patient to make his/her own health care decisions]

Ethics Center content
When Patients Refuse Treatment (IN fOCUS December 2005) [PDF]
Ten Myths about Decision-Making Capacity (NEC Report September 2002) [PDF]
Ten Myths About Decision-Making Capacity (NET Summary November 2002) [Word]
Source Patient HIV Testing in Patients Who Lack Decision-Making Capacity (NET Summary October 2002) [Word]
Common Pitfalls in Determining Decision-Making Capacity-Live from the National Ethics Committee Meeting (NET Summary March 2001) [Word]

Informed Consent for Clinical Treatments & Procedures  (VHA Handbook 1004.1) [PDF]

Non-VA content
EPERC Fast Fact and Concept
   #055 - Decision Making Capacity   

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1.b Informed consent process [providing information to the patient/surrogate, ensuring that the decision is voluntary, documenting the decision]

Ethics Center content
Informed Consent Do's and Don'ts for Best Practice (IN fOCUS August 2006) [PDF]
“Teach Back”: A Tool for Improving Provider-Patient Communication (IN fOCUS April 2006) [PDF]
When Must Clinicians Obtain a Separate Consent for Use of Blood Products in the Post-Operative Period? (Ethics Rx August 2006) [PDF]
Who May Serve as Witness for Signature Consent for Clinical Treatments and Procedures? (Ethics Rx December 2005) [PDF]
Consent for HIV Testing: Must the Patient's Signature on VA Form 10-0121 Be Witnessed? (Ethics Rx December 2004) [PDF]
Informed Consent for HIV Testing: Ethical Issues (NET Summary June 2004) [Word]
Ethics Rounds: Substituted Judgment or Best Interests? (news@vhaethics Summer 2003) [PDF]
Informed Consent Policy Revision (NET Summary January and February 2003) [Word]
Informed Consent Policy Revision: Medical Decision Making in Patients Without Surrogates (NET Summary January 2002) [Word]
Informed Consent for IV Contrast Administration (NET Summary January 2001) [Word]

Informed Consent for Clinical Treatments & Procedures (VHA Handbook 1004.1) [PDF]

Non-VA content
EPERC Fast Fact and Concept
   #056 - What to do when a patient refuses treatment  

UW Ethics in Medicine
   Informed Consent  
   Informed Consent in the Operating Room  

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1.c Surrogate decision making [selection, role, and responsibilities of the person authorized to make health care decisions for the patient]

Ethics Center content
Ethical Aspects of the Relationship between Clinicians & Surrogate Decision Makers (NEC Report April 2007) [PDF]
National Ethics Committee Report: Ethical Aspects of the Relationship between Clinicians & Surrogate Decision Makers  (NET Summary April 2007) [Word]
May Clinicians Disclose Health Information Protected Under 38 U.S.C. §7332 to Surrogates? (Ethics Rx February 2006) [PDF]
Choosing Among Surrogates of the Same Priority (Ethics Rx April 2005) [PDF]
Ethical Issues in Long-Term Care (VHA Bioethics Committee, 2000) [PDF]
Disclosing Patients’ Protected Health Information to Surrogates (NEC Report February 2005) [PDF]
Disclosing Patients' Protected Health Information (NET Summary February 2005) [Word]

Non-VA content
AMA Code
   E-8.081 - Surrogate Decision Making  

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1.d Advance care planning [statements made by a patient with decision-making capacity regarding future health care decisions]

Ethics Center content
Advance Directives for Mental Health: An Ethical Analysis of State Laws & Implications for VHA Policy  (February 2008) [PDF]
National Ethics Committee Report: Advance Directives for Mental Health: An Ethical Analysis of State Laws & Implications for VHA Policy  (March 26, 2008) [Word]
Advance Care Planning and Management of Advance Directives (NET Summary March 2007) [Word] 
How Can Patients Communicate Their Wishes About Life-Sustaining Treatment? (Ethics Rx March 2005) [PDF]
Must All Patients Be Asked About Mental Health Advance Directives? (Ethics Rx February 2005) [PDF]
Strategies to Make Advance Care Planning More Effective: Best Practices (NET Summary March 2003) [Word]
Legal Briefs: Advance Directives: VA vs. non-VA forms (news@vhaethics Spring 2001) [PDF]
Best Practices: Advance Care Planning (news@vhaethics Spring 2001) [PDF]
Ethical Issues in Advance Directives for Behavioral Health Care (NET Summary May 2003) [Word]
Ethical Issues in Long-Term Care (VHA Bioethics Committee, 2000) [PDF]

Advance Care Planning and Management of Advance Directives   (VHA Handbook 1004.2) [PDF]

• New advance directive form, VA Form 10-0137, VA Advance Directive - Durable Power of Attorney for Health Care and Living Will [PDF] and patient education and information sheets, VA 10-0137A, Your Rights Regarding Advance Directives [PDF], and VA 10-0137B, What You Should Know About Advance Directives [PDF]

Non-VA content
EPERC Fast Fact and Concept
    #012 - Myths about Advance Directives  

UW Ethics in Medicine
    Advance Care Planning   

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1.e Limits to patient choice [e.g., choice of care setting, choice of provider, a demand for unconventional treatment]

Ethics Center content
Ethical Considerations When Treating Erectile Dysfunction in Patients with Sexually Transmissible Diseases (NET Summary May 2004) [Word]
Should Patients be Able to Refuse Care by House Officers or Trainees? (NET Summary March 2004) [Word]
Ethics Rounds: Patient Refusal of Care by a Trainee (news@vhaethics Summer/Fall 2002) [PDF]

Non-VA content
CMAJ Bioethics for Clinicians
   Dealing with Demands for Inappropriate Treatment  

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1.f Other

Ethics Center content
Ethics and the Discharge Process: What to Consider When a Patient Prefers a Plan that the Team Believes is Unsafe  (NET Summary May 28, 2008) [Word]
Strategies for Increasing Influenza Vaccination Rates in Health Care Workers: Ethical Considerations  (January 30, 2008) [Word]
National MRSA (Methicillin-Resistant Staphylococcus Aureus) Initiative: Ethical Considerations in Implementation (October 2007) [Word]
Impaired Driving in Older Adults: Ethical Challenges for Health Care Professionals  (NEC Report September 2007) [PDF]
National Ethics Committee Report - Impaired Driving in Older Adults: Ethical Challenges for Health Care Professionals (NET Summary September 2007)
Informed Consent Practices: Lessons Learned from Implementing iMedConsent (NET Summary November 2006) [Word] 
Best Practices: Click Here for Informed Consent (news@vhaethics Summer 2003) [PDF]

Non-VA content
EPERC Fast Fact and Concept
   #052 - Quality of Life  

 

 

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Ethical Practices in End-of-Life Care

Cardiopulmonary resuscitation (CPR)
Life-sustaining treatments
Medical futility
Hastening death
Death and postmortem issues
Other

 

Overview
IntegratedEthics Online Learning Module: Ethical Practices in End-of-Life Care

Goals of Care in the ICU: Palliative Care at the End of Life (IN fOCUS January 2005) [PDF]
Weighed in the Balance: Ethical Decisions at the End of Life (news@vhaethics Spring 2001) [PDF]

UW Ethics in Medicine
   End of Life Issues  

2.a Cardiopulmonary resuscitation (CPR) [withholding/stopping resuscitation in the event of cardiopulmonary arrest, including DNAR orders]

Ethics Center content
Adverse Events and the Management of DNR Orders: Ethical Considerations (NET Summary September 2006) [Word] 
May Do-Not-Resuscitate (DNR) Orders Be Suspended for Surgery? (Ethics Rx January 2005) [PDF]
What Does DNR Really Mean? (NET Summary June 2005) [Word]
DNR FAQs  [PDF]
Clarification of VA Do Not Resuscitate (DNR) Policy—Orders Written by Residents (Ethics Rx May 2003) [PDF]
Do Not Resuscitate Policy Revision: Controversial Topics (March 2002) [Word]
Policy Perspectives: Should Residents Be Allowed to Enter DNR Orders? (news@vhaethics Summer/Fall 2002) [PDF]
Family Presence During Resuscitation (NET Summary August 2001) [Word]
Ethics Rounds: Wristbands for DNR? (news@vhaethics Fall 2002) [PDF]
DNR Orders and Medical Futility (NEC Report December 2000) [PDF]
DNR Orders and the Electronic Medical Record (NET Summary December 2000) [Word]

Do Not Resuscitate (DNR) Protocols within the Department of Veterans Affairs (VHA Handbook 1004.3) [PDF]

Non-VA content
EPERC Fast Fact and Concept
   #023 - DNR Orders in the Hospital Setting - Part I 
   #024 - DNR Orders in the Hospital Setting - Part II 

UW Ethics in Medicine
   Do Not Resuscitate Orders 
   Do Not Resuscitate Orders during Anesthesia and Urgent Procedures 

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2.b Life-sustaining treatments [withholding or stopping artificially administered fluid or nutrition, mechanical ventilation, dialysis, surgery, antibiotics, etc.]

Ethics Center content
State-Authorized Portable Orders: Out of Hospital DNR Orders and Orders for Life-Sustaining Treatment (NET Summary July 2007) [Word] 
Ethical Considerations of Cardiac Pacemakers and Implantable Defibrillators for End-of-Life Care (NET Summary April 2006) [Word] 
Caring for Patients in Persistent Vegetative State (IN fOCUS March 2005) [PDF]
Terminal Extubation: Ethics Perspectives (NET Summary March 2005) [Word]
Life Sustaining Treatments and Vegetative State: Implications of the March 2004 Papal Allocution for VHA Health Care (NET Summary October 2004) [Word]
Catholic Teaching on Artificially Administered Nutrition & Hydration (IN fOCUS December 2004) [PDF]
Legal Briefs: Must Food and Fluids Always be Provided? (news@vhaethics Fall 2002) [PDF]

State-Authorized Portable Orders (VHA Handbook 1004.04) [PDF] 

Informed Consent for Clinical Treatments & Procedures (VHA Handbook 1004.1) [PDF]

Non-VA content
EPERC Fast Fact and Concept
   #111 - Cardiac Pacemakers at End of Life 
   #112 - Implantable cardioverter Defibrillator (ICD) at End of Life 
   #133 - Non-Oral Hydration in Palliative Care 

UW Ethics in Medicine
   Termination of Treatment 

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2.c Medical futility [a physician's judgment that a therapy will be of no benefit to a patient and that it should not be offered or should be withdrawn]

Ethics Center content
DNR Orders and Medical Futility (NEC Report December 2000) [PDF]
Futility Guidelines: A Resource for Decisions about Withholding and Withdrawing Treatment (VHA Bioethics Committee, 2000) [PDF]

Non-VA content
UW Ethics in Medicine
   Futility 

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2.d Hastening death [intentionally or unintentionally, e.g., questions related to euthanasia, assisted suicide, or the doctrine of double effect]

Ethics Center content
Physician-Assisted Suicide (VHA Bioethics Committee, 2000) [PDF]

Non-VA content
EPERC Fast Fact and Concept
   #008 - Morphine & Hastened Death 
   #156 - Evaluating Requests for Hastened Death 

CMAJ Bioethics for Clinicians
   Euthanasia and Assisted Suicide 

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2.e Death and postmortem issues [determination of death, organ donation, autopsy, disposition of body or tissue, etc.]

Ethics Center content
Practicing Medical Procedures on the Newly Dead (NET Summary November 2003) [Word]
Ethical Priority of Decedent's vs. Family's Wishes in Organ Donation (NET Summary July 2002) [Word]
Privacy Requirements During the Organ Donation Process (NET Summary January 2001) [Word]

Non-VA content
EPERC Fast Fact and Concept
   #079 - Discussing organ donation with families 
   #004 - Death Pronouncement 
   #115 - Declaring Brain Death 

AMA Virtual Mentor
   Family Disagreement over Organ Donation 

CMAJ Bioethics for Clinicians
   Brain Death 

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2.f Other

Ethics Center content
Ethics Rounds: Appropriate Palliative Care? (news@vhaethics Spring 2001) [PDF]

Palliative sedation -
The Ethics of Palliative Sedation (NEC Report March 2006) [PDF]
National Ethics Committee Report: The Ethics of Palliative Sedation as a Therapy of Last Resort (NET Summary July 2006) [Word]  
Terminal Sedation: An Open Discussion (NET Summary August 2002) [Word]

Non-VA content
EPERC Fast Fact and Concept
   #106 - Controlled Sedation for Refractory Suffering - Part I 
   #152 - The Military History as a Vehicle for Exploring End of Life Care with Veterans 

CMAJ Bioethics for Clinicians
   Quality End of Life Care 

 

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Patient Privacy and Confidentiality

Privacy
Confidentiality
Other

Overview
IntegratedEthics Online Learning Module: Patient Privacy and Confidentiality

3.a Privacy [protecting individuals' interests in maintaining personal space free of unwanted intrusions and in controlling data about themselves]

Ethics Center content
Patients' Requests to Have Their Medical Records Amended (NET Summary May 2006) [Word] 
The Ethical Challenges of Coordinating Mental Health Care Between VHA and DoD (NET Summary March 2006) [Word]
Privacy, Safety and Patient Social Security Numbers: Ethics Concerns (NET Summary July 2005) [Word]
Privacy, Safety, and Social Security Numbers (IN fOCUS February 2005) [PDF] Note: Since this IN fOCUS was published, VHA Directive 2005-029, Transfusion Verification and Identification Requirements for All Sites (July 1, 2005) [PDF] has been issued. It requires that "all patients reporting for hospital admission or ambulatory procedure must be issued a patient identification wristband that contains the patient's full name, full social security number (SSN) and a bar code that displays the patient's full SSN."
Online Patient-Clinician Messaging: Fundamentals of Ethical Practice (NEC Report July 2004) [PDF]
National Ethics Committee Report, Online Patient-Clinician Messaging: Fundamentals of Ethical Practice (NET Summary September 2004) [Word]
Ethics Rounds: Wristbands for DNR? (news@vhaethics Fall 2002) [PDF]
Ethical Issues in Long-Term Care (VHA Bioethics Committee, 2000) [PDF]
Privacy Requirements During the Organ Donation Process (NET Summary January 2001) [Word]

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3.b Confidentiality [nondisclosure of information obtained as part of professional-patient relationship]

Ethics Center content
May Clinicians Disclose Health Information Protected Under 38 U.S.C. §7332 to Surrogates? (Ethics Rx February 2006) [PDF]
The Ethical Challenges of Coordinating Mental Health Care between VHA and DoD (NET Summary March 2006) [Word]
Shared Medical Appointments: Ethical Concerns (NET Summary October 2005) [Word]
The Ethical Duty to Protect Third Parties from Dangerous Patients (NET Summary April 2005) [Word] 
Disclosing Patients’ Protected Health Information to Surrogates (NEC Report February 2005) [PDF]
Disclosing Patients' Protected Health Information (NET Summary February 2005) [Word]
Consent for HIV Testing: Must the Patient's Signature on VA Form 10-0121 Be Witnessed? (Ethics Rx December 2004) [PDF]
Informed Consent for HIV Testing: Ethical Issues (NET Summary June 2004) [Word]
Provider Reporting of Impaired or Potentially Impaired Drivers (NET Summary February 2002) [Word]


Non-VA content
UW Ethics in Medicine
   Confidentiality 

CMAJ Bioethics for Clinicians
   Confidentiality 

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3.c Other

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Professionalism in Patient Care

Conflicts of interest
Truth telling
Difficult patients
Cultural/religious sensitivity
Other

 

Overview
IntegratedEthics Online Learning Module, Professionalism in Patient Care

UW Ethics in Medicine 
   Professionalism 
   Physician-Patient Relationship 

4.a Conflicts of interest [situations that may compromise the clinician's fiduciary duty to patients, including inappropriate business or personal relationships]

Ethics Center content
Compensation to Health Care Professionals from the Pharmaceutical Industry (NEC Report February 2006) [PDF]
National Ethics Committee Report: Compensation to Health Care Professionals from the Pharmaceutical Industry (NET Summary February 2006) [Word]
Ethical Boundaries in the Patient-Clinician Relationship (NEC Report July 2003) [PDF]
National Ethics Committee Report: Ethical Boundaries in the Patient Clinician Relationship (NET Summary September 2003) [Word]
Gifts to Health Care Professionals from the Pharmaceutical Industry (NEC Report October 2003) [PDF]
National Ethics Committee Report: Gifts to Health Care Professionals from the Pharmaceutical Industry (NET Summary January 2004) [Word]
Ethics Rounds: Sale of House to a Patient? (news@vhaethics Winter 2001) [PDF]
Professional Conflicts of Interest for VHA Clinicians (VHA Bioethics Committee, 2000) [PDF]

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4.b Truth telling [open and honest communication, including disclosing bad news, adverse events]

Ethics Center content
Disclosure of Adverse Events to Patients: Ethical and Policy Requirements  (February 26, 2008) [Word]
Clinical Use of Placebo: An Ethics Analysis (NET Summary July 2004) [Word]
Disclosing Adverse Events to Patients (NEC Report March 2003) [PDF]
National Ethics Committee Report: Disclosing Adverse Events to Patients (NET Summary April 2003) [Word]
Notification of Patients Potentially Exposed to Mad Cow Disease Through Prior Blood Transfusion: Testing the Limits of Full Disclosure (NET Summary April 2001) [Word]

Disclosure of Adverse Events to Patients (VHA Directive 2008-002) [PDF]

Non-VA content
EPERC Fast Fact and Concept
   #006 - Delivering Bad News, Part I 
   #011 - Delivering Bad News, Part II 
   #021 - Hope and Truth Telling 

AMA Virtual Mentor
   Medical Error Disclosure 

UW Ethics in Medicine 
   Breaking Bad News 
   Truth Telling and Witholding Information 
   Mistakes 

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4.c Difficult patients [clinician interactions with patients who are disruptive or who do not adhere to treatment plans/health care recommendations]

Ethics Center content
Ethical Considerations in the use of Home Oxygen for Patients and/or Third Parties Who Smoke (July 30, 2008) [Word] (Audio not available)   Executive Summary and other resources [Word]
Ethics and the Discharge Process: What to Consider When a Patient Prefers a Plan that the Team Believes is Unsafe  (NET Summary May 28, 2008) [Word]
When Patients Refuse Treatment (IN fOCUS December 2005) [PDF]
Ethical Considerations in Opioid Therapy for Chronic Pain (IN fOCUS April 2005) [PDF]
Ethical Considerations in Opioid Therapy for Chronic Pain Management (NET Summary November 2005) [Word]
The Ethical Duty to Protect Third Parties from Dangerous Patients (NET Summary April 2005) [Word]  
Ethics Rounds: Patient Refusal of Care by a Trainee (news@vhaethics Summer/Fall 2002) [PDF]
Home Oxygen for Patients Who Smoke: Prescription vs. Proscription (NET Summary October 2001) [Word]
Managing 'Difficult' or 'Non-Compliant' Patients: Ethical Challenges (NET Summary September 2001) [Word]

Non-VA content
AMA Virtual Mentor
   Who is Being Difficult? Addressing the Determinants of Difficult Patient-Physician Relationships 
   When a Nonadherent Patient Needs Your Care 
   Stigmatized Patients' Right to Equal Treatment 

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4.d Cultural/religious sensitivity [clinician interactions with people of different ethnicity, religion, sexual orientation, gender, age, etc.]

Ethics Center content
Cultures and Persons, Patients and Caregivers: Ethical Obligations and Culturally Competent Care (NET Summary August 2003) [Word]
An Ethical Analysis of Ethnic Disparities in Health Care (NEC Report August 2001) [PDF]
An Ethical Analysis of Ethnic Disparities in Health Care (NET Summary December 2002) [Word]

Conscience -
The Conscience Clause (NET Summary June 2002) [Word]

Duty to Treat -
Influenza Pandemic Preparedness Planning: Ethics Concerns (NET Summary June 2006) [Word] 
Best Practices: A Duty to Treat (news@vhaethics Fall 2003) [PDF]
Health Care Ethics Issues Raised by SARS (NET Summary June 2003) [Word]
Ethics Rounds: Taking Risks to Protect Patients (news@vhaethics Fall 2003) [PDF]
Disaster Medicine: Unique Ethical Challenges (NET Summary April 2002) [Word] 

Non-VA content
EPERC Fast Fact and Concept
   #120 - Physicians and Prayer Requests 

UW Ethics in Medicine 
   Spirituality and Medicine 

AMA Virtual Mentor
   Ethics and Multiculturalism 
   Physician Values 
   Professional Demands and Religious Observance 

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4.e Other

Ethics Center content
Best Practices: Teaching Ethics and Professionalism (news@vhaethics Summer/Fall 2002) [PDF]

Miscellaneous -
Patients' Requests to Have Their Medical Records Amended (NET Summary May 2006) [Word] 
Online Patient-Clinician Messaging: Fundamentals of Ethical Practice (NEC Report July 2004) [PDF]
National Ethics Committee Report, Online Patient-Clinician Messaging: Fundamentals of Ethical Practice (NET Summary September 2004) [Word]
Protection Against "Gag Rules:" Safeguarding Provider-Patient Relationships (VHA Bioethics Committee, 2000)[PDF]

Pain/suffering -
Relief of Patients' Suffering: An Ethical Overview of a Practical Responsibility  (VHA Bioethics Committee, 2000)[PDF] 

Non-VA content
AMA Virtual Mentor
   Self-Regulation 
   Impaired Physicians 
   Peer Reporting 
   "Competent and Irrascible" 
   Protection for Conscientious Objection 
   Obligation to Provide Services 

UW Ethics in Medicine 
   Student Issues 
   Interdisciplinary Team Issues 

 

 

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Ethical Practices in Resource Allocation

Systems level (macroallocation)
Individual level (microallocation)
Other

Overview
IntegratedEthics Online Learning Module, Ethical Practices in Resource Allocation

5.a Systems level (macroallocation) [how well the facility demonstrates fairness in allocating resources across programs and services]

Ethics Center content
Influenza Pandemic Preparedness Planning: Ethics Concerns (NET Summary June 2006) [Word] 
Staff Discussion Forums on Ethics Issues in Pandemic Influenza Preparedness [Word]
Tough Decisions: Preparing VA for the Ethical Challenges of Pandemic Influenza   [PowerPoint]
Policy Perspectives: The Administrator's Dilemma (news@vhaethics Fall 2003) [PDF]
Ethical Considerations in Equitable Allocation and Distribution of Limited Health Care Resources (VHA Bioethics Committee, 2000) [PDF]
Ethics Consultation on Certain Questions of Enrollment (VHA Bioethics Committee, 2000) [PDF]
Ethical Considerations for a Multicultural Clinical Workforce (VHA Bioethics Committee, 2000) [PDF]

Non-VA content
The Hastings Center
The Five People You Meet in a Pandemic - and What They Need from You Today [PDF]

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5.b Individual level (microallocation) [how well the facility demonstrates fairness in allocating resources to individual patients or staff]

Ethics Center content
Ethics in Managed Care: Web-based Learning (news@vhaethics Spring 2002) [PDF]
Guidelines for the Allocation of Unproved Treatments (VHA Bioethics Committee, 2000) [PDF]
Allocation of Expensive Medications (VHA Bioethics Committee, 2000) [PDF]

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5.c Other

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Ethical Practices in Business and Management

Leadership
Human resources
Business integrity
Other

 

Overview

6.a Leadership [behaviors of leaders in support of an ethical environment and culture]

Ethics Center content

Non-VA content

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6.b Human resources [supervisory support for an ethical environment and culture through the high performance management system]

Ethics Center content

Non-VA content

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6.c Business integrity [practices that support oversight of business practices, compliance with legal and ethical standards, and promotion of business quality and integrity]

Ethics Center content
Copying, Pasting, and Duplicating in the Electronic Medical Record: An Ethical Analysis (NET Summary February 2004) [Word]
The Relationship Between Ethics and Compliance and Business Integrity (NET Summary July 2001) [Word]
Legal Briefs: Integrating Documentation, Compliance, and Ethics (news@vhaethics Spring 2002) [PDF]
Integrating Ethics with Compliance. Council of Ethical Organizations.

Non-VA content

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