Ethics in Nursing

Moral courage

What is moral courage? Moral courage is the courage to take action for moral reasons despite the risk of adverse consequences What does CODE stand for? C - courage O - obligation D - danger management E - expression and action

Code of ethics

•A set of statements encompassing rules that apply to people in professional roles -We follow ANA code of ethics

Code of ethics - ANA

•American nurses association code of ethics - Professional codes of ethics function as a guide to the highest standards of the ethical practice for nurses. They are not legally binding. Remember every ethical decision you make (big or small) you may have to defend legally someday. -Ethical things aren't always legal things. So nothing telling you what you have to do

Accountability

•An ethical duty stating that one should be answerable legally, morally, ethically or socially for one's activities

Veracity

•An ethical duty to tell the truth

Nonmaleficence

•An ethical principal stating the duty to not inflict harm •Different than beneficence which is to do good, this is to NOT do harm

Beneficence

•An ethical principle of compassion and patient advocacy. To promote goodness kindness and charity

Deontology

•An ethical theory stating that moral rule is binding

Utilitarianism

•An ethical theory stating that the best decision is one that brings about the greatest good for the most people -Decision based on what's best for everyone involved

Ethical decision making

•Answering difficult questions •Balancing science and morality •Moral issues •Health care decisions

Paternalism

•Based on health care provider's belief about what is in the best interest of the patient, he/she chooses to reveal or withhold patient information such as diagnosis, tx and prognosis •Used to be this way -Say you should do this b/c I say so and no choice in care -Outcomes for pt with this doesn't go well, patient's have to have a say in the plan of care for it to be successful

Autonomy (self-determination)

•Concepts of freedom and informed consent are grounded in this principle •Autonomy - personal freedom and the right of competent people to make choices (whether we like the decision or not)

Values

•Customs, ideas of life, and ways of behaving that society regards as desirable

Ethical frameworks - deontological theory

•Deontological theory -Emmanuel Kant 18th century -Duty based reasoning - duty to do something or refrain from doing something -Right based reasoning - individuals have basic inherent rights that should not be interfered with -Each individual has basic claims, entitlements, with which there should be no interference -Instituitionist framework - each case weighed on case by case basis to determine relative goals, duties and rights -Do best for each individual no matter what. Don't worry about society overall •Example -A decision is made to resuscitate and provide mechanical ventilation to a 20-week, otherwise viable fetus despite ability to pay for care and availability of newborn intensive care beds and only 95% chance it will live

Ethical scenarios

•First and foremost...Is it legal? •Who are your stake holders and how might your decision affect them? •Have you assessed the risks associated with your actions? •How does your organization expect you to represent them? •Can you defend your actions should the information become public? •Are your actions aligned with your own personal beliefs?

Ethical profession

•Gallup poll on professional honesty and ethics indicate that the public ranks nursing as the most ethical of all professions

Research subjects

•IRB (internal review board) - came out of Halocaust -protect the rights and welfare of research subjects -Adhere to ethical principles articulated by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research •Nuremberg code -Set of provisions for research that must be followed for fed govt. to approve research •You can stop a study at any time, can't make you stay

Learning right and wrong

•Infants -Begin with no concept of right or wrong •School-age children -Learn that good behavior is rewarded and bad behavior is punished •Adolescent -Questions existing moral values and his or her relevance to society •Adult -Strives to make sense of the contradictions and learns to develop own set of morals and values

Law VS Ethics

•Legal is typically clear and philosophically impartial •Ethical is much less clear and more individualized (gray area)

Ethical committees

•Many facilities have committees that assist in problem solving ethical issues •Core element of collaborative decision making should include representative of all stakeholders, including patients -Nursing is always represented in ethics committee

American Nurses Association Code of Ethics

1. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. 2. The nurse's primary commitment is to the patient, whether an individual, family, group, or community. 3. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient. 4. The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient care. 5. The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth. 6. The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action. 7. The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development. 8. The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs. 9. The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.

A client who is about to receive preoperative medication before surgery expresses doubts about the surgery and tells the nurse she is thinking about not having the surgery. In considering what reply to make to the client, the nurse determines that which nursing role is of highest priority at this time? A. Advocate B. Care manager C. Direct caregiver D. Educator

A Rationale: The highest priority of the nurse at this time is to fulfill the role of client advocate. Although the nurse is a direct caregiver and may also be a care manager, these are not the priority. The role that is critical to this scenario is the role of an advocate, in which the nurse lets the client know the decision to have surgery belongs to the client. The nurse may also utilize the role of educator to help allay any unfounded concerns, but this role would become important only after the nurse fulfills the role of advocate.

Select the ethical term that is accurately paired with it brief description. A. Deontology: The school of ethical of thought that requires that only the means to the goal must be ethical. B. Utilitarianism: The school of ethical of thought that requires that only the end goal must be ethical. C. Deontology: The school of ethical of thought that requires that only the end goal must be ethical. D. Utilitarianism: The school of ethical of thought that requires that only the means to the goal must be ethical.

B Rationale: The two major classifications of ethical principles and ethical thought are utilitarianism and deontology. Deontology is the ethical school of thought that requires that both the means and the end goal must be moral and ethical; and the utilitarian school of ethical thought states that the end goal justifies the means even when the means are not moral.

What ethical principle below is accurately paired with a way that ethical principle is applied into nursing practice? A. Justice: Equally dividing time and other resources among a group of clients. B. Beneficence: Doing no harm during the course of nursing care. C. Veracity: Fully answering the client's questions without any withholding of information. D. Fidelity: Upholding the American Nurses Association's Code of Ethics

C

A nurse seeking to uphold which ethical principle would allow a client who has residual deficits from a stroke to complete as much of the bath as possible while remaining at the bedside to provide assistance when needed? A. Justice B. Veracity C. Autonomy D. Fidelity

C Rationale - Autonomy promotes client dignity and self-worth by allowing clients self-determination and decision making. The principle of justice implies all clients are treated fairly. The principle of veracity is conveying truth to clients . And fidelity is the duty to keep promises.

A 15-year old teenager confides in a nurse that she is ready to engage in sexual activity with her boyfriend. How should the nurse respond? A. "Unfortunately, I'll have to tell your mother about this." B. "we can make an appointment with a gynecologist." C. "How do you plan to pay for your doctor's visit?" D. "Have you had any conversations with your parents about this?"

D Rationale: D allows the nurse to assess whether the teenager has spoken to her parents about sexual behavior, and it opens the door to communication. The nurse should not discuss this with the teenager's mother (A); the teenager has a right to confidentiality. And B and C does not address the affective need the teenager expresses

Moral development theory

Kohlberg •Preconventional stage -Morality is about rules posed by some authority •Conventional stage -Want to conform to certain social and religious morals •Postconventional stage -An autonomous thinker who strives for moral code beyond issues of authority and reverence (few reach this level) -Make decisions based SOLELY on what you think

Moral decision making model

•Massage the Dilemma: Collect data about the ethical problem and who should be involved in the decision making process •Outline options: ID alternatives, and analyze the causes and consequences of each (pros and cons list) •Review criteria and resolve: Weight the options aainst the values of those involved in the decision •Affirm position and act: Develop the implementation strategy •Look back: Evaluate the decision making This is very similar to the nursing process

Deontology

•Moral righteousness is the act that is determined not by the consequences of the actions it produces, but by the intentions and moral qualities intrinsic to the act itself (saving a premature baby and not looking at consequences/problems in their future)

Ethics committee

•Policy development •Education •Resolve ethical dilemmas

Code of ethics

•Professional code of ethics - set of principles, established by a profession meant to guide an individual practitioner •Outlines the general values, duties and responsibilities that flow from the specific role of being a nurse. Functions as guide for highest ethical practice standards for nurses and as an aid for moral thinking •American nurses association (ANA) code of ethics •International council of nurses' code of ethics for nurses

Ethics

•Science or study of moral values

How to promote ethical behavior as the norm

•Separate legal and ethical issues •Collaborate through an ethics committee •Use institutional review boards (IRB's) appropriately (every institute has one) •Foster an ethical work environment

Ethical frameworks - Teleological theory

•Teleological Theory (aka Utilitarianism/Consequentialist) -Provides the greatest good for the greatest number of people -Needs and wants for an individual are diminished -End justifies the means •Example -Utilitarianism - For instance if the government made a decision to forego Medicare funding treatment for patients 90 years of age and older with Alzheimer's and redistributed that money to other recipients it deemed to have a greater likelihood of benefit to longevity or quality of life -Hospital given money must decide how it will benefit the most people -PSA levels and mammogram screenings not done for younger people b/c costly and don't think it's really needed. Benefits more people b/c not enough money and not that many benefit from early screenings in their mind

Ethically sensitive issues

•Termination/refusal of tx •POA - family fights that pt wasn't of sound mind •Abortion/sterilization •Child abuse - putting child back with parent that abused them •Human experimentation •Genetic screening/genetic engineering - making baby you want •Stem cell therapy - from aborted babies, embryos, umbilical cord •Right to health care •Allocation of scarce resources - happens a lot with meds when enough can't be produced and have to decide who the small amount goes to

Fidelity

•The agreement to keep promises and commitments, based on the virtue of caring

Ethical sensitivity

•The capacity to decide with intelligence and compassion, given uncertainty in a care situation, with an additional ability to anticipate consequences and the courage to act -We may be put in unethical situations and have to decide how to act

Rights of conscience

•The civil right that protects conscientious health care providers against discrimination, allowing them the right to act according to the dictates of the conscience -Example: plan B came out and pharmacies wouldn't fill it -They can choose not to do something like sign off on abortion -This gives you the right to refuse to participate in tx etc you don't believe in -Best if you are upfront and honest about this

Ethics acculturation

•The didactic and experiential process of developing ethical reasoning abilities as part of ongoing professional preparation -Can change over time

Justice

•The equal and fair distribution of resources regardless of other factors

Bioethics

•The study of ethical problems resulting from scientific advances -Most ethical issues stem from this -Such as in vitro fertilization, removal of unused zygotes, organ transplantation

Ethics

•The systematic study of what a person's conduct and actions should be with regard to self, other human beings and the environment •A system of moral conduct and principles -Guide actions in regard to right and wrong -Guides actions in regard to self and society •More gray area than legal

Morals

•The values and beliefs held by a person that guide behavior and decision-making -Formed from our background and our upbringing

Ethical Frameworks

•Various frameworks/models used to help with ethical decision making •The frameworks do not answer the problem, however, they help the nurse clarify their personal values and beliefs •We will discuss a few, but remember there are many other frameworks that can be used as well