Chapter 43 Ethics and Values (Study the section on Professional guidelines [Nursing Code of Ethics] & Ethical issues in healthcare] ▪️highlighted asterisks ▪️
An ethical agent must be able to do the following
***perceive the difference between right and wrong ***understand abstract ethical principles ***reason and apply ethical principles to make decisions, weight 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)
Feminist theories do use
***principles and consequences, but they also ask you to look at gendered, cultural, and socially diverse issues in the ethical situations, especially those involving women
Autonomy
***refers to a person's right to choose and ability to act on that choice ***it is based on respect for humanity dignity
Values clarification
***refers to the process of becoming conscious of and naming one's values
Feminist ethical reasoning uses
***relationships and stories rather than universal principles
Distributive justice
***requires fair distribution of both benefits and burdens ***allocating resources ***fair access to care
You should analyze whether the treatment causes more harm than good
***risk of harm is not always clear ***weighing risks and benefits is value-laden exercise
International Council of Nurses
***serves as the standard for nurses worldwide ***stresses respect for human rights, including cultural rights, the right to life and choice , the right to dignity, and the right to be treated with respect
ANA Standards of care
***sets standards for all aspects of clinical practice
Factors that contribute to the frequency of nurses' ethical problems include
***societal factors ***the nature of nursing work ***and the nature of the nursing profession itself
Moral or ethical agency for nurses is
***the ability to base their practice on professional standards of ethical standards of ethical conduct and to participate in ethical decision making ***means nurses have choices and are responsible for their actions
Utilitarianism
***the most familiar consequentialist theory, asserts that the value of 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
Rights and duties
***major concepts derived from deontological framework are rights (the right to freedom, the right of self-determination) and duties (obligations) ***nurses have the duty to help others and accept their decisions even if they produce some bad consequences
Admitted patients are entitled to specific rights in terms of their treatment
***make their own decisions ***be active partners in the treatment process ***be treated with dignity and respect
Moral distress
***occurs when nurses are unable to act as moral agents
Impaired nursing practice
***occurs when the nurse's ability to perform the essential nursing functions is diminished by chemical dependence on drugs or alcohol or by mental illness ***nurses are required to report impaired nurses to their nursing leadership
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
Respect for dignity
refers to the nurse's respect for the intrinsic worth of each person, without respect to age, race, religion, medical condition, or any other factors
The Patient Care Partnership (Patients Bill of Rights)
encourages healthcare providers to be more aware of the need to treat patients in an ethical manner and to protect their rights ***when patients are admitted to hospitals or to extended care facilities, they are entitled to specific rights in terms of their treatment the right to: ▪️make their own decisions ▪️be active partners in the treatment process ▪️be treated with dignity and respect
Societal factors
****Increased consumer awareness ***Technological advances ***Multicultural population ***Cost containment (clients sent home sooner; increased number of patients per nurse)
Advocacy
***is the communication and defense of the rights and interests of another ***includes protecting patient's legal or moral rights (eg taking appropriate action when the actions of a provider jeopardize the patient's rights or best interest)
Veracity
***is the duty to tell the truth
Justice
***is the obligation to be fair ***equal treatment of all clients ***can be distributive, compensatory, procedural in focus
Value system
***is your value set ranked from most important to least important
The American Nurses Association
***it establishes the ethical standard for the profession and serves as a guide for nurses to use ethical analysis and decision making
The purposes of the nursing 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
Feminist ethics
*** is based on the belief that traditional ethical models provide a mostly masculine perspective and that they devalue the moral experience of women
The principles of privacy and confidentiality
*** support the principle of autonomy
As a nurse
*** you will always need to consider the consequences of your actions; you will almost never be able to decide only on the basis of principles and rules
Professional Values
****Altruism ***Autonomy ***Human dignity ***Integrity ***Social justice
American Association of Colleges of Nursing (AACN) Values
****Altruism - concern for the welfare and wellbeing of others; includes patient advocacy ***Autonomy - the right to self determination (to choose and act on that choice) ***Human dignity - respect for the inherent worth and uniqueness of individuals and populations ***Integrity - acting in accordance with an appropriate code of ethics and accepted standards of practice; includes honesty ***Social justice - upholding moral, legal, and humanistic principles; treating others fairly regardless of race, age, citizenship, economic status, disability, or sexual orientation; this value is reflected in professional practice when the nurse works to ensure equal treatment under the law and equal access to quality healthcare
Bioethics
****Application of ethical principles to every aspect of healthcare ***Is concerned with every area of healthcare including direct care of patients, allocation of resources, utilization of staff, and medical and nursing research
Whistleblowing
***A whistleblower is a person who reveals information about practices of others that are perceived as wrong, fraudulent, corrupt, illegal, or a detriment to the health, safety, and welfare of the clients they serve Risks and Consequences ***Nurses must carefully weigh their ethical obligations to advocate for clients against their obligations to the employer ***Whistleblowing can have harmful and long-lasting effects on the nurse's personal and professional lives; the impact can be loss of employment, fear of physical violence, and rejection by colleagues Etiology ***Moral outrage occurs when unresolved moral distress leads to anger, disgust, and powerlessness; the anger or outrage is directed toward individuals or groups perceived as responsible for the wrongdoings, acts, or policies that created the threat to one's personal and/or professional integrity, values or beliefs ***A nurse may respond to moral outrage by becoming a whistleblower Interventions Actions: to determine whether to ACT or THINK: Assess the nature of the action, the likelihood of immediate harm, and the accuracy and completeness of your data ***In some situations, you will ACT by immediately reporting situations that involve an immediate threat to the health, safety, and well-being of others ***In other situations, THINK ^^^Talk with an attorney or other legal representative. Whistleblowing laws must be strictly followed ^^^Have concrete and credible evidence of the violation and 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; weigh the risks against the benefits ^^^Know your reporting options and support systems that can correct the problems Rationale ***THE ANA CODE OF ETHICS, Provision 3.5, Protection of Patient Health and Safety by Acting on Questionable Practice, guides the need to support nurses who become whistleblowers "All nurses have a responsibility to assist whistleblowers who identify potentially questionable practices that are factually supported in order to reduce the risk of reprisal against the reporting nurse
Ethical questions arise in the following situations
***Abortion ***Acquired immune deficiency syndrome (AIDS) ***Advanced directives ***Allocation of healthcare goods and services compelling unwanted treatment ***Confidentiality and privacy (eg reporting gunshot wounds and child abuse) ***Do Not Attempt Resuscitation (DNAR)/ Allow Natural Death (AND) orders ***Euthanasia, assisted suicide, aid in dying , extraordinary (heroic) measures to prolong life ***Informed consent ***Organ transplantation ***Reproductive technology (eg in-vitro fertilization, surrogate mothering, sex preselection) ***Withdrawing or withholding life-sustaining treatments (ventilators, artificial nutrition, hydration)
Professional values frequently cited for nursing include
***Aesthetics (qualities of objects or people that are pleasing) ***Caring ***Competence, excellence (skill knowledge, performance of nursing work) ***Diversity ***Education (basic and lifelong continuing education for nurses) ***Equality (having the same rights, privileges, or status) ***Excellence ***Freedom (capacity to choose) ***Holism ***Loyalty (feeling of duty or attachment to other nurses ***Service (commitment to work useful to others) ***Truth (faithfulness to fact or reality)
Moral Concepts and Principles
***Autonomy ***Nonmaleficence ***Beneficence ***Fidelity ***Veracity ***Justice
Nurses Obligations
***Be aware and sensitive to issues ***Assume responsibility ***Be a team member ***Support patient and family ***Participate in ethics committee ***Be a patient advocate
The nature of the nursing profession
***Caring versus time spent with clients (understaffing, heavier client loads; the use of technology; the need for careful documentation; the nursing emphasis on leading, managing, and delegating instead of hands-on client care ***Autonomy versus escaping hard choices - ( many nurses are uncomfortable making the hard choices and prefer to let the provider decide) ***Higher pay versus cost-effectiveness ***Professionalism versus caring -
The following are two issues that may arise when using a deontology framework
***Conflict of universal principles ***Evaluating motives - it is important to consider motives ( motives may place more weight on one of the conflicting universal principles over the other and make a decision clearer
Moral Frameworks
***Consequentialism ***Deontology ***Ethics of care ***Feminist ethics
Diagnoses for clients struggling with ethical issues
***Decisional Conflict- use this label when the patient is uncertain about which course of action to take; the patient may verbalize distress or uncertainty; may delay decision making; increased heart rate ***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
What factors affect ethical decisions?
***Developmental Stage: Kohlberg 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 (final level that occurs in adulthood ***Values, Attitudes, and Beliefs
Nursing Ethics
***Ethical questions that arise out of nursing practice ***subset of bioethics
Using utilitarianism to address an ethical problem requires you to engage in a risk-benefit analysis
***Evaluate every alternative action for its potential outcomes, both positive (pros) and negative (cons) - similar to a technique you may already use in making other decisions ***Then select the action that results in the most benefits for the greatest number of people involved in the situation
Remember this general nursing principle:
***Every competent adult has the right to accept or refuse treatment and should be provided all the information needed to make an informed decision
Ethics
***Formal process for making logical and consistent moral decisions **is the study of a system of moral principles and standards, or the process of using them to decide your conduct and actions
Beneficence
***is a duty to do or promote good ***continuum with nonmaleficence ***Do no harm - Prevent harm - Remove harm - Bring about positive good
Procedural justice
***is important in processes that require ranking or ordering For example : institutional policies are written to ensure that the same procedures apply to all clients or employees in the same way
A person whose behavior is not consistent with traditional notions of right or wrong
***is labeled as immoral
Moral behavior
***is that which is consistent with customs or traditions based on the external influence
Modes of Value Transmission
***Modeling - children learn values from a variety of role models by observation ( modeling can lead to socially acceptable or unacceptable behaviors) ***Moralizing - (this is the only way) children are taught a complete set of values in an authoritarian approach, if the child does not conform, the parent may inflict guilt and fear on him ( this approach by parents, teachers, church leader etc make it difficult for young people to make independent choices because they have no experience selecting values that are good for them ***Laissez-faire- (doing your own thing) children are allowed to explore differing sets of values on their own with little guidance or discipline (this may lead to conflict and confusion on the part of the child) ***Reward and punishment- the child's behavior is controlled by offering rewards for certain valued behaviors and punishing the child who fails to comply (rewards can strengthen behavior, whereas physical punishment may teach that violence is an acceptable behavior) ***Responsible choice - a balance of freedom and restriction allows children to select the values, explore new behaviors, and experience the consequences (having choices can result in personal satisfaction and parental support)
Morals
***Private, personal, or group standards of right and wrong ***are learned from external influences and communicated through various systems (religious, political, educational, societal)
Ethical Decision Making
***Problem-solving ***Assessment - What are relevant facts? ***Analysis/Diagnosis- Identify problem; state the conflict
Personal Values and Morality
***Set of values chosen to help live a good life ***Internalized societal values
Beliefs
***a belief us something that one accepts as true ***beliefs are sometimes based on faith and sometimes on facts ***a belief may or may not be true ***our beliefs may be altered by acquiring knowledge and experiences ***beliefs may or may not involve values
Whistleblowing
***a nurse may respond to moral outrage by "blowing the whistle"
Key point
***always consider the context
Ethical rules and principles
***an analysis of a situation to determine which actions are right or wrong uses ethical rules and principles, such as justice, autonomy, doing good, and doing no harm
Ethics of care
***an ethics of care nursing philosophy directs attention to the specific situations of individual clients, viewed within the context of their life narrative ***care is not viewed as an obligation, but as a responsibility based on your relationship with the person ***emphasizes the role of feelings, but also includes some of the principles that are part of traditional ethics, such as autonomy (self-determination) or beneficence (doing good)
Values and morals are learned in conscious and unconscious ways
***and become a part of your makeup
Professional codes of ethics
***are formal statements of a group's expectations and standards for professional behavior generally accepted by members of the profession
Nurses' Ethical Problems
***are immediate, serious, and frequent
Attitudes
***are mental dispositions or feelings toward a person, object or idea ***they can be cognitive (thinking), affective (feeling), and behavioral (doing) ***are our way of responding to situations or things
Ethical or moral frameworks
***are systems of thought (theories) that are the basis for the differing perspectives people have in ethical situations ***using more than one framework to analyze a situation enables you to perform a more comprehensive analysis of the problem
The following guidance is derived from the ethics of care philosophy
***caring is viewed as a central responsibility gif nurses ***knowing the client's story promotes dignity and respect for the client as a person ***your relationship and professional competence allow you to meet the client's needs ***you should cultivate a habit of care that includes virtues such as kindness, attentiveness, empathy, compassion, and reliability
The Joint Commission Accreditation Standards
***contain sections on organizational ethics and individual rights ***the patient's values, preferences, need for information, and other factors that promote autonomy must be considered in her plan of care
Professional values
***expansion of personal values as you move forward in your profession
Fidelity
***faithfulness - is a duty to keep promises ***basic part of every nurse-client relationship
Compensatory Justice
***focuses on making amends for wrongs that have been done to individuals **malpractice suits consider this type of justice when they decide how much money to award a victim for being harmed ***the goal is to make the person "whole"
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
Patients when hospitalized should expect the following
***high quality care, including the right to know the identity of caregivers ***a clean, safe environment, including safety, freedom fro abuse and neglect, and discussion of any changes in care ***respect for healthcare goals, values, and spiritual beliefs ***to be involved in making decisions about their care and treatment (this includes receiving information about: health condition and treatments; the benefits and risks of treatments, and whether a treatment is experimental or part of a research study; what the patient and family will need to do regarding treatment follow-up after leaving the hospital ***information about the right to make decisions and to refuse care, including advance directives and counselors or chaplains available to help with decision making ***protection of privacy and confidentiality ***help reviewing the bill and filing insurance claims ***preparation and information when leaving the hospital, including: identification of sources for follow-up care and whether the hospital has a financial interest in any of the referrals; coordination of hospital activities with caregivers outside the hospital ; information and training about the self-care the person will need at home
American Nurses Association Code of Ethics for Nurses
***the nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person *** the nurse's primary commitment is to the patient, whether an individual, family group, community, or population ***the nurse promotes, advocates for, and protects the rights, health, and safety of patient ***the nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent wit the obligation to promote health and to provide optimal care ***the nurse owes the same duties to self as to others, including the responsibility to promote health and safety , preserve wholeness of character and integrity, maintain competence, and to continue personal and professional growth ***the nurse, through individual and collective effort, establishes, maintains, and improves the ethical that are conducive to safe, quality of care ***the nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health ***the nurse collaborates with other health professionals and the public to protect human rights, to promote health diplomacy, and reduce health disparities ***the profession of nursing, collectively through its professional organizations must articulate nursing values, maintain the integrity of the profession, and integrate principles of social into nursing and health policy
Informed consent
***the principle of autonomy incorporates informed consent - the right of competent patients to decide whether to agree to a proposed treatment
Nonmaleficence
***the principle of nonmaleficence is the twofold duty to 1) do no harm 2) prevent harm ***it encompasses actual harm, risk of harm and intentional and unintentional ***requires that you think critically and identify the potential risks and benefits in the treatment
Consequentialist theories
***the rightness or wrongness of an action depends on the consequences of the act rather than the act itself
Nurses have multiple obligations and relationships that can create conflicting loyalties
***they are employees (with a relationship with the agency) and professionals (with a special relationship with clients and interprofessional team members) ***nurses are expected to follow the provider's prescriptions for client care, although the provider is not the nurse's employer ***in most organizations providers are higher on the power and status hierarchy than are nurses
No matter how well you know the theories, they will not provide the "right" answers for what to do in a specific patient situation
***they merely offer a lens through which you can examine an ethical problem
Ethical concepts and principles are useful in client care discussions because
***they provide a common language for healthcare professionals to identify the issues
Treat people as ends and never as means
***this means the person is more important than the goal you may be trying to accomplish
The study of ethics prepares you
***to analyze ethical dilemmas from multiple perspectives rather than relying entirely on your personal values, intuition, and emotions
Healthcare professionals have an obligation to society
***to be competent in their field ***to allow only qualified persons entry into the profession ***to discipline members of the profession who do not practice at an acceptable level ***to do no harm ****and to use high moral and ethical standards to resolve dilemmas
Practice in analyzing dilemmas will help you
***to become an informed decision maker, capable of understanding the perspectives of everyone in a situation
The Code of Ethics is designed
***to guide nurses in everyday choices, and supports their refusal to participate in activities that conflict with caring and healing
You demonstrate respect for autonomy when you
***treat clients with consideration ***believe clients' stories about the course and symptoms of their illnesses ***protect those who are unable to decide for themselves ***protect privacy and confidentiality ***you honor autonomy when you respect the client's or surrogate decision maker's right to decide, without judgement, even when yo believe those choices are not in the client's best interest
Paternalism
***treating others like children ***can have negative outcomes ***lacks respect for the patient's autonomy
Deontology
***uses rules, principles and standards to determine whether an action is right or wrong ***the consequences of the act are not the major considerations
You should consult professional guidelines
***when making ethical decisions
It is important to clarify the influence of your values each time
***you enter into a situation in which you are called on to be objective in your decision making
When you are careful to prevent medication errors or use an ambulation belt for assisting patients to walk
***you honor the nonmaleficence principle
To promote autonomy
***you should educate clients and encourage them to formulate advance directives to ensure they have a voice in their long term treatment
Why should nurses study ethics
***you will frequently encounter ethical problems in your work (most difficult question, "should I do this?" ***ethics is central to nursing ***multidisciplinary input is important ***ethical knowledge is necessary for professional competence ***ethical reasoning is necessary for nursing credibility among other disciplines (you must be able to understand your own values as they relate to basic morality and use ethical reasoning to articulate your moral position) ***ethical proficiency is essential for providing holistic care ***nurses have a responsibility to be advocates for patients ***studying ethics will help you to make better decisions
To fulfill your obligations for ethical practice
***you will need practical knowledge of the processes of values clarification, ethical decision making, patient advocacy, and integrity producing compromise
Value set
***your list of values ***it gives direction for your life and forms a basis for behavior
To maintain trust you should
**discuss information relevant to client care in approved areas (conference rooms, bedside) and not in areas where others can overhear you (eg hallways, cafeterias, elevators ***share information with team members who have a need to know based on their involvement in the client care ***obtain the client's consent before providing information to family members or friends ***do not post pictures of clients on social media sites
Values
**is a belief you have about the worth of something ***it serves as a principles or a standard that influences your decision making ***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 **people express their values through behaviors, feelings, knowledge, and decisions ***highly individualized ***can change and vary with new experiences and thoughtful consideration
Personal value system
A set of values that you have reflected on and chosen that will help you to lead a good life
The Categorical Imperative
An ethical guideline developed by Immanuel Kant under which an action is evaluated in terms of what would happen if everybody else in the same situation, or category, acted the same way.
MORAL Model
M - Massage the dilemma O - Outline the options R - Resolve the dilemma A - Act by applying the chosen option L - Look back and evaluate
Example problem
Moral distress ***Diagnosis - response to the inability to carry out one's chosen ethical/moral decision/action ***Defining characteristics- mental anguish and or physical pain based on involvement in a moral situation; feelings of frustration, anger, emotional exhaustion ***Etiology - Internal constraints (relationships with others; lack of skills, confidence, and courage; fear; concerns about perceptions of others) - External constraints (time, power imbalances, lack of institutional support, policies and procedures, threat of lawsuits, regulatory directives) ****Outcomes - Decreased level of anxiety, lack of fear, psychospiritual comfort status, spiritual health, preservation of personal autonomy and integrity, relief from frustration and anger ***Interventions - ***recognize the source of the moral distress, ***understand your values, thoughts, and beliefs, ***reflect on your values that are threatened in the situation (are they personal or professional values) ***engage in values clarification, ***self-manage emotions; discuss with a mentor if you are having difficulty, ***make decisions based on reasoned choices, ***discuss the basis of your decision with the members of the interprofessional team, client, and family members, ***be sure to express to express it logically and clearly and with controlled emotions, *** view the situation from the other perspective (identify reasons that support this perspective, this helps to ensure that you have a comprehensive knowledge of factors that led to the other person's decision,*** engage with personal and professional resources to resolve intrapersonal conflicts that occur when decisions are made that are contrary to your selected choice, ****accept that clients have the right to make decisions that they feel best adhere to their values and beliefs (treat them with kindness and show compassion; the patient is also experiencing some type of loss in these situations), ***make a commitment to care for self; *** acknowledge your feelings and seek support sources, separate personal from professional, ***engage in self-care activities (exercise, meditation, reflection, recreational activities, adequate sleep, balanced diet); ***seek spiritual guidance and support; ***develop a network of supportive interprofessional colleagues; ***seek counseling for unresolved feelings or development of moral outrage (anger directed toward others)
American Nurses Association Standards of Professional Performance Standard 7 [Ethics]
The registered nurse: ▪️Integrates the Code of Ethics for Nurses with Interpretive Statements to guide nursing practice and articulate the moral foundation of nursing ▪️Practices with compassion and respect for the inherent dignity, worth, and unique attributes of all people ▪️Advocates for healthcare consumers' rights to informed decision-making and self-determination ▪️Seeks guidance in situations where the rights of the individual conflict with public health guidelines ▪️Endorses the understanding that the primary commitment is to the healthcare consumer regardless of setting or situation ▪️ Maintains therapeutic relationships and professional boundaries ▪️Advocates for the rights, health, and safety of the healthcare consumer and others ▪️Safeguards the privacy and confidentiality of healthcare consumers, others, and their data and information within ethical, legal , and regulatory parameters ▪️Demonstrates professional accountability and responsibility for nursing practice ▪️Maintains competence through continued personal and professional development ▪️Demonstrates a commitment to self-reflection and self-care ▪️Integrates principles of social justice into nursing and policy ▪️Contributes to the establishment and maintenance of an ethical environment that is conducive to safe, quality health care ▪️Advances the profession through scholarly inquiry, professional standards development, and the generation of policy ▪️Collaborates with other health professionals and the public to protect human rights, enhance cultural sensitivity and the public to protect human rights, promote health diplomacy, enhance cultural sensitivity and congruence, and reduce health disparities ▪️Articulates nursing values to maintain personal integrity and integrity of the profession
