Annals of Long Term Care

Justice is a complex ethical principle, with meanings that range from the fair treatment of individuals to the equitable allocation of healthcare dollars and resources. Justice is concerned with the equitable distribution of benefits and burdens to individuals in social institutions, and how the rights of various individuals are realized.¹

Common definitions for Justice are often problematic for clinicians, as the explanations leave many questions unanswered. If Justice is a concept about treating people fairly, then it is prudent to wonder what it means to be “fair.” In discussing a different aspect of Justice, distributive Justice, the concern focuses on who gets what treatment in healthcare, and who decides what treatments are administered. Is the decision based on need? Age? Prognosis?² These concepts leave clinicians with many unanswered questions as to what is fair and equitable in the treatment of individuals.

In light of the challenges inherent in defining Justice, it is fair to say that it is a concept involving fairness, equality, and equitable treatment. Specifically, Justice involves the application of fairness to individuals in population groups or communities. In order to apply Justice in any scenario, individual factors should be examined on their own merit. Each scenario is unique and should be addressed accordingly.

Consider what Justice means within a small patient population or community. For example, the long-term care (LTC) setting has a community of residents, all of whom live together and interact with staff on a daily basis. The daily pressures of regulatory compliance, process improvement, and attention to clinical outcomes in LTC can threaten the consistent application of Justice, as can the pressures on facility administration to maintain staff morale.

In making policy and in establishing standards of practice in LTC, it is imperative to uphold the principle of Justice. More specifically, residents should receive care that is fair and equitable, and upholds their basic rights as equal citizens in a shared community. Objective criteria for resident treatment must prevail over emotional or subjective approaches.

An example of violating the ethical principle of Justice is outlined below in a case involving the rights of staff versus residents to smoke on facility grounds. A LTC facility designed a policy to eliminate resident smoking both inside and outside of the facility building. However, the facility’s policy continued to allow staff to smoke in designated smoking areas where residents were prohibited.

Case Example
A LTC facility was concerned that some of its residents were at increased risk for advancing illness by continuing to smoke cigarettes. In order to reduce the risk of advancing illness, the facility enacted a policy that prevented all facility residents from smoking anywhere on facility grounds.

The staff discussed this policy with the residents, their families, and physicians, and collectively developed a program to aid the residents in gradually withdrawing from smoking. The residents were in agreement with this request and complied with the smoking cessation program. In fact, three residents stopped smoking, felt enhanced well-being, and enjoyed more fulfilling activities to occupy their time that had previously been spent smoking.

However, the facility allowed staff to continue to smoke on facility grounds. It became uncomfortable for the three residents who had quit smoking to watch staff smoke in the same designated areas from which they were now restricted.