Chapter 22: Ethics

The ethics of care suggests that ethical dilemmas can best be solved by attention to relationships. How does this differ from other ethical practices? Select all that apply. 1) Ethics of care pays attention to the environment in which caring occurs. 2) Ethics of care pays attention to the stories of the people involved in the ethical issue. 3) Ethics of care is used only in nursing practice. 4) Ethics of care focuses only on the code of ethics for nurses 5) Ethics of care focuses only on understanding relationships.

1,2,5 Ethic of care focuses on environmental issues affecting care, the narratives of the patients and health care providers, and understanding relationships.

Beneficence

Taking positive actions to help others a. Fundamental to the practice of nursing and medicine b. Agreement to act with beneficence implies that the best interests of the patient remain more important than self-interest

Utilitarianism

measures good and bad by measuring the effect that an act will have, measures value by usefulness a. Also known as consequentialism= the value of something is determined by its usefulness, main emphasis is on the outcome or consequence of action i. Main emphasis is on the outcome or consequence of an action b. Teleology= the greatest good for the greatest number of people is the guiding principle for determining right action in this system

Fidelity

Agreement to keep promises a. As a nurse, you keep promises by following through your actions and interventions b. Fidelity also refers to the unwillingness to abandon patients regardless of the circumstances, even when personal beliefs differ as they may when dealing with drug deals, members of the gay community, women who receive an abortion, or prisoners.

Which of the following properly applies an ethical principle to justify access to health care? select all that apply 1) Access to health care reflects the commitment of society to principles of beneficence and justice. 2) If low income compromises access to care, respect for autonomy is compromised. 3) Access to health care is a privilege in the United States, not a right. 4) Poor access to affordable health care causes harm that is ethically troubling because nonmaleficence is a basic principle of health care ethics. 5) Providers are exempt from fidelity to people with drug addiction because addiction reflects a lack of personal accountability. 6) If a new drug is discovered that cures a disease but at great cost per patient, the principle of justice suggests that the drug should be made available to those who can afford it.

1,2,4 Justice is the ethical principle that justifies the agreement to ensure access to care for all, but it does not necessarily clarify how to resolve issues of limited resources such as money or organs available for transplant. Privilege is not an ethical principle. Nonmaleficence means "first do no harm." A lack of care because of poor access causes harm (i.e., no preventive services, no early detection, no risk reduction) and therefore is ethically troubling. The principal of fidelity implies that we agree to ensure access to care even for people whose beliefs and behaviors may differ from our own, including drug addicts.

The nurse is explaining to students the difference between nonmaleficence and beneficence. Which information should the nurse include in the explanation to help the students understand the two concepts? Select all that apply. 1) According to the concept of beneficence, all interventions should consider the patient's best interest. 2) According to the concept of beneficence, maximum priority is given to patients by allowing them to make their own healthcare decisions. 3) According to the concept of nonmaleficence, the healthcare provider should weigh the risks and benefits of the intervention before delivering it. 4) According to the concept of nonmaleficence, the nurse should be loyal and not abandon the patient even when the treatment procedure is complicated. 5) According to the concept of nonmaleficence, the nurse should keep promises by following through on actions and interventions.

1,3 The principle of beneficence is fundamental to the practice of nursing and medicine. The agreement to act with beneficence implies that the best interests of the patient remain more important than self-interest. Nonmaleficence is the avoidance of harm or hurt. According to this concept, the healthcare professional tries to balance the risks and benefits of care while striving to do the least harm possible. Autonomy refers to the commitment to include patients in decisions about all aspects of care as a way of acknowledging and protecting a patient's independence. According to the concept of fidelity, a healthcare professional should be unwilling to abandon patients even when care becomes controversial or complex. In addition, the nurse should follow through on actions and interventions.

The senior nurse is teaching a group of nursing students about healthcare ethics. Which actions are examples of the nurse showing respect for a patient's autonomy? Select all that apply. 1) Ensuring that the patient understands the risks of a medical procedure 2) Keeping promises by following through on any interventions 3) Including the patient's needs when organizing nursing care delivery for the day 4) Asking the patient to read and sign an informed consent before surgery 5) Receiving permission from the patient before performing a physical examination

1,4,5 Autonomy refers to the patients' right to make their own decisions. The nurse shows respect for a patient's autonomy by ensuring that the patient understands the risks of a medical procedure and by asking the patient to read and sign an informed consent before surgery. Seeking and receiving permission from a patient before performing a physical examination shows respect for the patient's autonomy. When nurses keep promises by following through on interventions, they are acting on the principle of beneficence, not respect for a patient's autonomy. When nurses act to meet the patient's best interests when giving nursing care, they are maintaining the standard of fidelity, not demonstrating respect for the patient's autonomy.

Healthcare institutions establish ethics committees to process ethical dilemmas. Which are purposes of ethics committees? Select all that apply. 1) Education 2) Patient teaching 3) Patient care 4) Case consultation 5) Policy recommendation

1,4,5 Ethics committees are usually multidisciplinary. They have several purposes such as education, case consultation, and policy recommendation. Any person involved in an ethical dilemma can request access to an ethics committee. Patient teaching and patient care are the responsibility of all members of the healthcare team.

ANA Code of Ethics for Nurses

1. Provides a foundation for professional nursing 2. ANA established the first code of ethics decades ago 3. ANA reviews and revises the code regularly to reflect changes in practice, however, basic principles of responsibility, accountability, advocacy, and confidentiality remain constant

Processing an Ethical Dilemma

1. Step 1: Ask if this is an ethical dilemma 2. Step 2: Gather all relevant information→ patient, family, institutional, and social perspectives are important sources of relevant information 3. Step 3: Clarify values→ distinguish among fact, opinion, and values 4. Step 4: Verbalize the problem→ a clear, simple statement of the dilemma is not always easy, but it helps to ensure effectiveness in the final plan and facilitates discussion 5. Step 5: Identify possible courses of action 6. Step 6: Negotiate the outcome/plan→ Negotiation requires a confidence in one's own point of view and a deep respect for the opinions of others 7. Step 7: Evaluate the action/ plan over time

It can be difficult to agree on a common definition of the word quality when it comes to quality of life. Why? Select all that apply 1) Average income varies in different regions of the country. 2) Community values influence definitions of quality, and they are subject to change over time. 3) Individual experiences influence perceptions of quality in different ways, making consensus difficult. 4) The value of elements such as cognitive skills, ability to perform meaningful work, and relationship to family is difficult to quantify using objective measures. 5) Statistical analysis is difficult to apply when the outcome cannot be quantified. 6) Whether or not a person has a job is an objective measure, but it does not play a role in understanding quality of life.

2,3,4,5 A person's average income and whether the person is employed are incorrect answers because income level is not necessarily a determining factor in measuring quality of life, but the ability to do meaningful work usually does influence the definition.

The senior nurse is discussing ethical dilemmas with colleagues. Which statements are true about ethical dilemmas? Select all that apply. 1) Nurses should consider personal views while processing ethical dilemmas. 2) Resolving ethical dilemmas includes discussions without any contradictions. 3) Ethical dilemmas should be processed carefully to reduce distress and controversy. 4) An ethical dilemma cannot be resolved solely through scientific data. 5) Resolving ethical dilemmas is similar to the nursing process.

3,4,5 Ethical dilemmas can cause distress and controversy, so they should be processed carefully and deliberately. An ethical dilemma cannot be resolved solely through scientific data; it requires negotiations of differences of opinions. Resolving ethical dilemmas is similar to the nursing process; it follows a methodical approach to come to a conclusion. Resolving ethical dilemmas includes discussions and negotiation of differences of opinion. The nurse should try to put personal views aside when working through an ethical dilemma.

A patient is admitted to a medical unit. The patient is fearful of hospitals. The nurse carefully assesses the patient to determine the exact fears and then establishes interventions designed to reduce these fears. In this setting how is the nurse practicing patient advocacy? 1) Seeking out the nursing supervisor to talk with the patient 2) Documenting patient fears in the medical record in a timely manner 3) Working to change the hospital environment 4) Assessing the patient's point of view and preparing to articulate it

4 Assessing the patient's point of view and preparing to articulate it best reflects the concept of advocacy because it is standing up for the patient and having his or her views and wishes heard.

Code of Nursing Ethics

A set of principles that all members of a profession accept i. Code of ethics is defined as a collective statement about the group's expectations and standards of behavior b. Helps professional groups settle questions about practice or behavior c. Includes advocacy, responsibility, accountability and confidentiality i. Advocacy: as a nurse you advocate for the health, safety, and right if the patients, including their right o privacy and their right to refuse treatment ii. Responsibility= willingness to respect obligations and to follow through on promises iii. Accountability= the ability to answer for one's own actions. Standards are set by the Joint Commission and the ANA; health care facilities have compliance officers who are responsible for making sure that the institution remains in compliance with standards and regulations iv. Confidentiality= Health Insurance Portability and ACCOUNTABILITY ACT OF 1996 (HIPAA) mandates the protection of the patient's personal health information

Autonomy

Commitment to include patients in decisions about all aspects of their care as a way of acknowledging and protecting a patient's independence a. Involving patients in decisions about their care is now standard practice b. Providers are obligated to inform patients about risks and benefits of treatment plans and then to ensure that they understand and agree with their plan c. Respect for provider autonomy refers to provider relationships to institutions

Value

Personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior a. Ethical dilemmas almost always occur in the presence of conflicting values b. To resolve ethical dilemmas, one needs to distinguish among values, facts, and opinions c. To negotiate differences of value, it is important to be clear about your own values: what you value, why, and how you respect your own values even as you try to respect those of others whose values differ from yours d. Values develop over time e. Sometime people have such strong values that they consider them to be facts rather than opinions f. Clarifying values, your own and your patients, is an important and effective part of ethical disclosure g. In the process of clarification, you learn to tolerate differences in a way that often (although not always) becomes the key to the resolution of ethical dilemmas

responsibility

willingness to respect one's professional obligations and to follow through (ex. Following agency's policies and procedures; delegation as a nurse)

Deontology

defines actions as right or wrong on the basis of their "right making characteristics" such as fidelity to promises, truthfulness and justice; does not look at consequences to determine right or wrong a. Proposes a system of ethics that is perhaps most familiar to health care practitioners. b. Depends on a mutual understanding of justice, autonomy, and goodness; but it still leaves room for confusion to surface

Social Networking

a. Presents ethical challenges for nurses b. Social networks can be a supportive source of information about patient care or professional nursing activities. The risk to patient privacy is great. c. Posting a photo with no identifiers should not be practiced, as sometimes, the patient can still be identified. d. Becoming friends with patients may cloud your ability to remain objective. e. Workplace policies will guide your decisions in engaging with social media

Nonmaleficence

avoidance of harm of hurt a. Maleficence refers to harm or hurt b. In health care, ethical practice involves not only the will to do good, but an equal commitment to do no harm

Justice

being fair a. Used most often in discussions about access to healthcare resources, including the distribution of resources b. The term just culture refers to the promotion of open discussion without fear of recrimination whenever mistakes, especially those involving adverse events, occur or nearly occur.

Casuistry

case based reasoning → an intimate understanding of particular situations a. Turns away from conventional principles of ethics as a way to determine best actions and focuses instead on an "intimate understanding of particular situations" b. This approach to ethical discourse depends on finding consensus more than an appeal to philosophical principle c. As a strategy to solving dilemmas, consensus building promotes respect and agreement rather than a particular philosophy or moral system itself

Feminist Ethics

looks to the nature of relationships to guide participants in making difficult decisions, especially relationships in which power is unequal or in which a point of view has become ignored or invisible a. Critiques conventional ethics such as deontology and utilitarianism b. Writers with a feminist perspective tend to concentrate more on practical solutions than on theory c. Feminist ethicists propose that the natural human urge to be influenced by relationships is a positive value d. Focuses on the inequality between people

Confidentiality

protection of patient's personal health information

Code of ethics

set of guiding principles that all members of a profession accept

Ethics of Care

strives to address issues beyond individual relationships by raising ethical concerns about the structures within which caring occurs (structures such as hospitals or universities) a. Promotes philosophy that focuses on understanding relationships, especially personal narratives b. An early component of the ethics of care used the term the one-caring to identify the individual who provides care, and the cared-for to refer to the patient or patients c. In adopting this language, the author hoped to emphasize the role of feelings

Ethics

study of conduct and character

Advocacy

support of a particular cause a. Nurses advocate for health, safety, and rights of patients, including their right to privacy and their right to refuse treatment

Accountability

the ability to answer for one's actions a. You ensure that your professional actions are explainable to your patients and employer b. Health care institutions have accountability by monitoring individual and institutional compliance with national standards established by agencies