Ethics and values chapter 43

Ethical questions that arise out of nursing practice

- What will your level of participation be in a given ethically challenging situation - Can you support the clients' decisions based on their ethical beliefs - What are your feelings about the results of decisions made by others?

Process for ethical practice

-Clarify your values clarification: This refers to the process of becoming conscious of and naming one's values (Burkhardt & Nathaniel, 2014). If you are clear about your values, you will be more able to make good decisions and to avoid imposing your values on others. Because each person has his own unique values set, it is important that you appreciate how others' values influence their decisions. -Identify moral dilemmas: Only problems that pose a question between competing and equally valuable interests are true dilemmas. Use a decision-making model: M, massage the dilemma; O, outline the options; R, resolve the dilemma; A, act by applying the chosen option; and L, look back and evaluate. -Look for a compromise: Even if you believe you know the right thing to do, others may not agree with you, or there may be constraints that prevent you from doing it. Many times, it will be possible to reach a "good" compromise. A good compromise is one that preserves the integrity of all parties. This means that: The discussions are carried out in a spirit of mutual respect—all viewpoints are respected and considered. The compromise solution itself is ethically sound. -Participate on an ethics committee: Ethics committees develop guidelines and policies, provide education and counseling, and in the case of ethical dilemmas, review the case and provide a forum for the expression of the diverse perspectives of those involved. Ethics committees usually follow one of three models when discussing a dilemma: the autonomy model, the patient benefit model, or the social justice model. -Improve your ethical decision making: Research has found that when faced with ethical dilemmas, nurses tended to use conventions (e.g., rules, procedures) as criteria for decision making rather than clients' personal needs and well-being. A full-spectrum nurse must move from the conventional (rules-bound) to the post-conventional (reasoning) stage of moral development. The following suggestions can provide guidance: Use theoretical knowledge: Review nursing and other literature for discussion of cases and experiences of other nurses. This will give you a broader view of the problems you may confront and the strategies for managing them. Become familiar with the codes of ethics, the Patient Care Partnership, and ethical frameworks and principles. Use self-knowledge: Examine your personal value system. Explore the influences of your religion, cultural beliefs, and personal experiences. This will help you to recognize your comfort zone with specific ethical issues. Use practical knowledge: While you are still a student, ask to attend either ethical rounds or an ethics committee meeting. Consult reliable sources: Attend ethics education programs and discuss issues with healthcare providers, attorneys, ethicists, and clergy to obtain the perspectives of others. Share: Regularly engage in discussions with the staff on your unit to determine differences in value systems and to collaborate proactively to identify methods to effectively resolve ethical dilemmas. When faced with a difficult ethical decision, seek guidance and support from peers, coworkers, and teachers. Evaluate: After a situation is resolved, evaluate your decision and the effects of your actions. You should be able to learn from even the worst decision. And when everything goes well, you can file your strategies away to use in similar future situations

Factors in Ethical Decision Making: attitudes

Attitudes Feelings toward person, object, idea Includes thinking and feeling component What a person thinks Attitudes are mental dispositions or feelings toward a person, object, or idea. Attitudes can be cognitive (thinking), affective (feeling), and behavioral (doing). For example, you might have a positive attitude about cleanliness; that is, you may think it is a good thing (e.g., "The floor is clean. That's nice.") But if you value cleanliness, you would be willing to scrub the floor. You would also wash your hands at appropriate times, bathe regularly, and teach others about hygiene

Ethical principles

Autonomy Nonmaleficence Beneficence Fidelity Veracity Justice

Autonomy

Autonomy refers to a person's right to choose and ability to act on that choice. It is based on respect for human dignity. You demonstrate respect for autonomy when you treat patients with consideration, believe their stories about the course and symptoms of their illnesses, and protect those who are unable to decide for themselves.

Factors in Ethical Decision Making:

Beliefs Something that one accepts as true Not always based on fact Beliefs are what one accepts as true (e.g., "I believe that germs cause disease and that by washing my hands I remove germs"). Beliefs are sometimes based on faith and sometimes on facts. A belief may or may not be true. Beliefs may or may not involve values

Beneficene

Beneficence is the duty to do or promote good. You can think of this principle as being on a continuum with nonmaleficence. At one end of the continuum is the duty to bring about positive good, beneficence, at the other end, is the duty to do no harm.

The nurse knows that a provider with type 1 diabetes became hypoglycemic while performing a bedside thoracentesis. The provider resisted assistance and finished the procedure despite being impaired. The nurse is upset by the provider's behavior. This is an example of nursing ethics. True False

Both a and b This example most directly involves the ethical behavior of the provider, so you might think it is not nursing ethics; however, it could be argued that the nurse has a duty to report impaired practice.

Categorical imperitice

Categorical imperative: This principle, established by the philosopher Immanuel Kant (1724-1804), states that one should act only if the action is based on a principle that is universal—or in other words, if you believe that everyone should act in the same way in a similar situation.

Professional Guidelines for Ethical Decision Making

Codes of Ethics for Nurses International Council of Nurses American Nurses Association Standards of care Patient Care Partnership The Joint Commission

Ethical frameworks

Consequentialism Teleology Utilitarianism Deontology Formalism Categorical imperative Feminist ethics Values relationships/stories Addresses female perspective of issues Ethics of care Nursing's responsibility to care in ethical situations Principles + feelings

Consequentialism

Consequentialism: The rightness or wrongness of an action depends on the consequences of the act rather than on the act itself. Theories of this type are also called teleology, from the Greek word telos, meaning "end" or the study of ends (also called final causes).

Ethical Problems for Nurses: Sources

Consumer awareness: As a result of increased consumer awareness and availability of information online, professionals now are expected to share knowledge with patients and to obtain truly informed consent for treatments. In some cases, consumers are demanding treatment that is not medically needed. Technological advances: With every new technology, new issues arise. For example, in vitro fertilization and embryo transfer methods have brought about questions of what should be done with embryos that are not implanted into a uterus. Can they be disposed of? What is their status as persons? Multicultural population: You will work with patients and colleagues from a variety of cultural backgrounds who probably hold very different sets of values. You will need to respect a variety of belief systems and serve as a patient advocate even when the patient's value system is very different from your own. Cost containment: The emphasis on cutting healthccare costs creates many morally questionable situations. For example, patients are being sent home from the hospital while they are still very ill. On being discharged, they may discover that insurance payments are limited for services outside the hospital, including specialists, home care, and medical supplies (e.g., bandages, walkers

Assessment/analysis/diagnosis

Decisional conflict Moral distress A holistic, comprehensive client assessment will help you establish the context in which ethical decisions are made. For clients struggling with ethical issues, the following diagnoses of may apply: Decisional conflict: Use this label when the patient is uncertain about which course of action to take. The patient may verbalize distress and uncertainty; may delay decision making; may show physical signs of distress (e.g., increased heart rate); and may question moral rules, values, and personal beliefs. Moral distress: Use this label when the patient has made a moral decision but is unable to carry out the chosen action. Cues include expressions of powerlessness, guilt, frustration, anxiety, self-doubt, and fear.

Deontology

Deontology is almost the opposite of the utilitarian model in that it considers an action to be right or wrong regardless of its consequences. Decisions are based on moral rules and unchanging principles.

Factors in Ethical Decision Making: Developmental Stage

Developmental stage: A person's stage of moral development affects the way he reasons about moral issues. We learn and internalize our morals throughout the life span, beginning in childhood. Kohlberg's research found that children go through a sequence of moral reasoning ability, proceeding through several stages. Stage I: Moral reasoning is based on personal interest and avoiding punishment. Stage II: Principles focus on pleasing others and following rules. Stage III: Moral principles are based on universal and impartial principles of justice. This is the final level; it occurs in adulthood. Gilligan challenged Kohlberg's perspective of moral development, citing it as being male-biased. Gilligan's research found that girls develop morally by paying attention to community and to relationships, whereas boys tend to process dilemmas through more abstract ideals or principles

Ethics

Ethics Systematic study of right and wrong conduct Formal process for making consistent moral decisions Ethics is a formal process for making logical and consistent moral decisions. Morals consider in a broad, general manner what is good or bad, right or wrong (e.g., "In general, it is wrong to steal"). Ethics answers the question, "What should I do in a given situation?" (e.g., "Is it wrong to steal if you have to do it to feed your children?"). Ethics uses specific rules, theories, principles, and perspectives to inquire into the justification of an individual's actions in a particular situation. It seeks to discover what we "ought" to do in certain circumstances

Ethics of care

Ethics of care: Nurses include a responsibility to care as a part of their professional behavior. Some aspects of care include the ability and duty to appreciate, understand, and even share the patient's pain or condition. Using a caring framework, your ethical analysis would focus on relationships and client stories. The following are specific ethics-of-care perspectives: -Viewing caring as the central force in nursing. -Promoting dignity and respect for patients as people. -Attending to the particulars of each individual patient, especially the marginalized and disenfranchised members of society. -Cultivating responsiveness to others. -Redefining fundamental moral principles to include virtues such as kindness, -attentiveness, empathy, compassion, and reliability

Feminist ethics

Feminist ethics: Feminist ethical reasoning uses relationships and stories rather than universal principles. Feminists argue that it is impossible to avoid being influenced by one's relationships. They see that influence as positive and believe it should not be lessened by an attempt to be objective—and in any case, that objectivity is impossible anyway.

Fidelity

Fidelity (faithfulness) is the duty to keep promises. It is a basic part of every patient care situation. Sometimes the promises are of major significance, such as promising not to share certain information with other members of the healthcare team. At other times it may be only a promise to come back to check the effectiveness of a pain medication or to bring a requested item back to the client's room. The duty to keep a promise is the same regardless of its level of importance.

International council of nurses (ICN)

International Council of Nurses (ICN): The ICN first adopted its Code of Ethics for Nurses in 1953. ICN Code has since served as the standard for nurses worldwide. The Code stresses respect for human rights, including cultural rights, the right to life and choice, the right to dignity, and right to be treated with respect.

Justice

Justice is the obligation to be fair. It implies equal treatment of all patients. Questions of justice will become a part of your everyday experience in patient care, from deciding how to allocate your time among patients to larger decisions, such as how to allocate limited healthcare resources.

Using the MORAL acronym for making an ethical decision, under which "letter" would the following action fall? The physician explains to the laboring woman the impact on the unborn child of refusing a cesarean birth. M L R O

The letter "O" in the MORAL acronym represents the step of outlining options. The physician would explain to the patient all of the consequences and options of either having or not having the C-section, and listen to the patient for her viewpoint.

The nurse was just hired to work in a hospice day care facility. She reflects on her ethical framework and decides that she believes in establishing relationships with an emphasis on caring. Which frameworks can the nurse use? Select all that apply. Deontology Feminist ethics Utilitarianism Ethics of care

The nurse can use the frameworks of feminist ethics and ethics of care. An ethics of care philosophy incorporates understanding the story of the person's life. It naturally incorporates care, which is viewed as a responsibility, as opposed to an obligation. It also focuses on the client's autonomy and promotes beneficence. A feminist ethics reasoning uses relationships and stories rather than universal principles. Feminists argue that relationships are positive and they use stories rather than universal principles. The theory of deontology focuses on "Doing." It is based on following the rules and regulations. Good is defined as adherence to guidelines and directives. The theory of utilitarianism focuses on "Thinking." It considers the best course of action which has the best outcome for the greatest number. This requires one to engage in a risk-benefit analysis to decide the best course of action

Utilitarianism

Utilitarianism takes the position that the value of an action is determined by its usefulness. The principle of utility states that an act must result in the greatest good (positive benefit) for the greatest number of people. Any act can then become the ethical choice if it delivers "good" results.

Factors in Ethical Decision Making: Values

Values Belief about the worth of something Highly prized ideals, customs, conduct, goals Freely chosen Learned through observation and experience Vary from person to person Can change Values are ideals, beliefs, customs, modes of conduct, qualities, or goals that are highly prized or preferred by individuals, groups, or society. You can value an idea, a person, a way of doing things, or even an object (e.g., money). People express their values through behaviors, feelings, knowledge, and decisions. For example, the nurse who values compassion will interact with patients in a sensitive, caring manner

Veracity

Veracity is the duty to tell the truth. This seems straightforward, and you may wonder why it even needs discussion. Most nurses would agree that it is not hard to tell the truth, but at times it may be very hard to determine how much of the truth to tell.

Consider the five components of ethical agency. To what extent do you believe nurses possess those abilities? Explain your thinking. How would you apply the components of ethical agency in a situation where a client is diagnosed as being brain-dead, yet the family insists that all care be continued?

What is ethical agency? Moral or ethical agency for nurses is the ability to base their practice on professional standards of ethical conduct and to participate in ethical decision making. Simply stated, it means that nurses have choices and are responsible for their actions. An ethical agent must be able to: Perceive the difference between right and wrong. Understand abstract ethical principles. Reason and apply ethical principles to make decisions, weigh alternatives, and plan sound ways to achieve goals. Decide and choose freely. Act according to choice (this assumes both the power and the capability to act). <<The students' responses will vary. >>

The joint commission

The Joint Commission Accreditation Standards: The Joint Commission standards contain sections on organizational ethics and individual rights. The section on organizational ethics requires ethical behavior in care, treatment, services, and business practices. The patient's values, preferences, need for information, and other factors that promote autonomy must be considered in her plan of care. It includes a statement about the need to provide for meeting patient needs in the event care must be denied in the institution. In meeting the patient's needs, you must also consider the organization's legal responsibility

Ethical problems for nurses (nature of work and profession)

-The nature of nursing work: Ethical problems exist in all kinds of work. However, the nature of nursing work can create unique ethical problems. Nurses' ethical problems are immediate, serious, and frequent. In the classroom, you have the luxury to leave questions unsettled. In the real world, you must always decide: Either you take action or you do not. For a nurse, deciding not to act is, in effect, an act. Nurses' unique position in healthcare organizations: Nurses have multiple obligations and relationships that can create conflicting loyalties. -The nature of the nursing profession: Some ethical problems arise because of value conflicts and a lack of clarity within the nursing profession. We have unresolved questions about the nature, scope, and goals of our practice, as well as our professional values. In most of the following examples, we value both of the opposites. We would not wish to give up either one, but specific situations require us to choose between them. That can be a source of discomfort. Caring versus time spent with clients: Nursing values caring, humanistic care, and nurse-client relationships, but nurses now spend less time at the bedside than ever before. One reason is understaffing and heavier client loads, but there are other factors: the use of technology; the need for careful documentation; and the nursing emphasis on leading, managing, and delegating instead of hands-on client care. Autonomy versus escaping hard choices: On one hand, we believe that nurses should have an equal status with other healthcare professionals. On the other hand, many nurses are uncomfortable making the hard choices and prefer to "let the provider decide." Higher pay versus cost-effectiveness: Most nurses believe we deserve higher pay, yet we claim nurses are cost effective because we work less expensively than the primary providers. Professionalism versus caring: We claim the nurse is a professional, citing critical thinking, knowledge, and management skills, yet we emphasize caring, with the nurse at the bedside offering comfort and doing hands-on tasks.

Codes of Ethics for Nurses

:The purposes of the code of ethics are to: Inform the public about the profession's minimum standards. Demonstrate nursing's commitment to the public it serves. Outline major ethical considerations of nursing. Provide general guidelines for professional behavior. Guide the profession's self-regulating functions. Remind us of the special responsibility we assume in caring for the sick

The CEO has begun to buy intravenous start kits from a new manufacturer to save money. The needle in the new kit has broken on several occasions during an IV start. The RN has tried unsuccessfully to have the CEO buy a different kit. Recently, several clients have been injured, when the needle broke off into their arm as the nurses entered the vein. The CEO blames the incidents on an "inappropriate technique" used by then nurses. The RN asks you if she should become a whistleblower. What is your best response? What additional information should be considered?

A whistleblower is a person who reveals information about practices of others that is perceived as wrong, fraud, corruption, illegal, or a detriment to the health, safety, and welfare of the clients they serve. In this situation, the acts of the CEO are putting clients at risk and also impeding safe nursing care when starting an IV. However, "blowing the whistle" can have serious negative consequences (e.g., isolation, loss of friends, punitive administrative actions, termination). Your best response should be one that requires the nurse to analyze the situation and to understand the ramifications on both her personal and professional life, The THINK model provides this guidance. -Talk with an attorney or other legal representative to understand the requirements of whistleblowing in the state. There are usually strict adherence requirements that the whistleblower must follow. Seeking legal advice may provide insight into other options. -Have concrete and credible evidence of the violation or wrongdoing. How often have these incidents occurred? Over what time period? What are the opinions of other nurses? Did the incident occur only after using the new start kits. What is the conclusion of the root cause analysis conducted after each incident? Are there other documented incidents against the new manufacturer? -Institute a survival plan if your job is put in jeopardy or you are fired. Fear of financial difficulty stemming from no job is a major reason why many people do not report wrongdoings. The work environment can socialize individuals to a certain amount of fear. Being terminated from one job can negatively impact future employment -Note the nature and consequences of the problem—its type, severity, and potential impact. Weigh the risks against the benefits. Consider the well-being of the clients versus the emotional, physical and social consequences that may be encountered. -Know your reporting options and support systems. Consider the internal sources available to correct the problem. For example, use the chain of command, risk management, or other departments. If the problem is still not corrected, consider external resources, such as The Joint Commission or other regulatory agencies

Whistleblowing

A whistleblower is a person who reveals information about the practices of others that he or she reasonably believes is corruption; mismanagement; fraud; abuse; illegal; or harmful to the health, safety, and welfare of the general public. You will need to consider the nature of the action, the likelihood of immediate harm, the accuracy, and the completeness of your data. If it involves an immediate threat to the health, safety, and well-being of others, you should report it immediately. In other situations, you should follow THINK: -Talk with an attorney or other legal representation. -Have concrete and credible evidence of the violation or wrongdoing. -Institute a survival plan, if your job is put in jeopardy or you are fired. -Note the nature and consequences of the problem—its type, severity, and potential impact. -Know your reporting options and support systems. The systems involved can correct the problems. Weigh the risks against the benefits

American Nurses Association (ANA)

American Nurses Association (ANA): The ANA revised their Code of Ethics for Nurses in 2015. It is relevant in many practice settings and reflects current ethical situations.

Nurses as ethical agents

Know the difference between right and wrong Understand abstract moral principles Apply moral principles in decision making Weigh alternatives; plan to achieve goals Decide and choose freely Act according to choice Moral agency or ethical agency for nurses is the ability to base their practice on professional standards of ethical conduct and to participate in ethical decision making. Simply stated, it means that nurses have choices and are responsible for their actions. An ethical agent must be able to: Perceive the difference between right and wrong. Understand abstract ethical principles. Reason and apply ethical principles to make decisions, weigh alternatives, and plan sound ways to achieve goals. Decide and choose freely. Act according to choice (this assumes both the power and the capability to act). What is value neutrality? You have probably been taught that nurses need to be nonjudgmental in working with their patients. As a nurse, you do have a duty to provide the best care to patients. You should not assume that your personal values are right, and you should not judge patients' values as right or wrong on the basis of whether they agree with your value system. Value neutrality means that we attempt to understand our own values regarding an issue and to know when to put them aside, if necessary, to become nonjudgmental when providing care to clients. However, many ethicists and some healthcare providers believe it is not possible to achieve value neutrality. Further, they say it is not even desirable because it obligates healthcare providers to suppress their own deepest moral and religious beliefs). It requires significant insight to recognize how your value-laden perspective impacts your perceptions and thus conclusion about a situation.

Moral distress

Moral distress -Inability to carry out a moral decision -Perceived constraints Physicians; nurse administrators; other nurses The law; threat of lawsuit

Moral outrage

Moral outrage -Belief that others are acting immorally -Powerlessness Cannot prevent a "wrong" Respond with "whistleblowing"

Morals

Morals Private, personal, or group standards of right and wrong Moral behavior, in accordance with custom, reflects personal moral beliefs

The client has right-sided hemiplegia as a result of a stroke (brain attack) and wants a cup of hot coffee. Even though the client is insistent, the nurse does not permit her to drink the coffee unsupervised. This nurse is using the ethical principle of Autonomy Fidelity Nonmaleficence Justice

Nonmaleficence While this is a simple example, the nurse is actually decreasing the risk of harm (a burn) by not leaving the client alone with hot coffee. Note that in this instance, the nurse judged the principle of nonmaleficence to be more important than the principle of autonomy.

Nonmaleficence

Nonmaleficence is the twofold duty to do no harm and to prevent harm. Nonmaleficence refers to both actual harm and risk of harm, as well as to intentional and unintentional harm. In nursing it is rare to find intentional harm, but unintentional harm due to lack of careful planning and consideration does occur (Beauchamp & Childress, 2012). Unintentional harm can also occur because of lack of knowledge, skill, or ability.

Patient Care Partnership

Patient Care Partnership: In the United States, the American Hospital Association (AHA) published a document called Patient Care Partnership (2003). Instead of using "rights" language, this document is written in terms of patient expectations and responsibilities.The Patient Care Partnership encourages healthcare providers to be more aware of the need to treat patients in an ethical manner and to protect their rights.