Ethical issues Concept: Professionalism Exemplar: ethical dilemmas

Nonmaleficence

•Do no harm! Example: •If you destroyed an employee's self esteem and self worth

Ethics of character

Character develops over time based on life experiences and our willingness to reflect on our actions and motives. Virtues are character traits that predispose a person with good intentions to act with practical wisdom. Moral virtues include respect, honesty, sympathy, charity, kindness, loyalty, and fairness, whereas practical virtues include intelligence, patience, prudence, and shrewdness.14 In general, a moral act must both promote good and intend good based on the moral predispositions of our character. The basic ethical question might be, "What is the wise action to take?"

Ethical decision-making framework

Ethical dilemmas involve situations in which a choice must be made between equally unacceptable options that an individual perceives he or she can accept and reasonably justify on a moral plane or in which there is not a more favorable choice that dominates the situation.

Ethics

Ethics is the study of standards of conduct and moral judgment. (right and wrong)

Ethics of relationship

Primary attention is paid to preserving relationships, improving communication, enhancing cooperation, and minimizing harm to everyone involved while promoting an ideal of caring.15 The basic ethical question in the ethic of care might be, "What is the caring response?"

Ethics committees

Provide a structure and guidelines for potential problems, serve as open forums for discussion, and function as true patient advocates by placing the patient at the core of the committee discussions.

Code of ethics

Purpose •Inform the public of minimum standards acceptable for conduct •Outline the major ethical considerations of the profession •Provide to its members guidelines for professional practice

What is moral distress?

When nurses cannot provide what they perceive to be best for a given patient(s).

ethical problem is simply a problem with an ethical dimension. Most ethical problems have

a reasonably clear solution, whereas others can be quite complex or involve competing ethical priorities. An ethical dilemma involves a problem for which in order to do something right you have to do something wrong. For example, in order to be loyal to one friend, you have to be disloyal to another. An example in patient care is determining whether aggressive treatment at the end of life will cause more harm than benefit. In other words, it is not possible to meet all of the ethical requirements in the situation. Instead, you must be sensitive to the ethical dimensions of the situation, able to use ethical concepts to analyze and reflect on the ethical conflicts within the dilemma, determine an ethically justifiable solution, and take action.

Ethics of Duty

is the right thing to do although the consequences of our actions are important, they are a secondary consideration to duty and our intention to do the right thing. The ethical question posed is, "What is my duty?" For example, if a nurse becomes aware that a friend and colleague has been diverting narcotics because she has developed an addiction, and the nurse reports her friend to her supervisor because that is what the organizational policy requires, she is complying with her ethical duty to report.

Fidelity

loyalty •Keeping one's promises or commitments. Example: •Promised leave time

One popular model for clinical decision making is the four topics method. The four topics are

medical indications, patient preferences, quality of life, and contextual features. Within each topic, questions are posed that clarify factual aspects of the case with an emphasis on common ethical principles. Answering the various questions provides a framework within which different options for action can be considered.

Any approach to ethical analysis will depend heavily on one's ability to ask good questions. Asking the wrong question or failing to ask an important question will generally result in a wrong or incomplete answer. An ethical question is a question that challenges you to consider a particular ethical concept, principle, or perspective in your analysis. The following are examples of ethical questions:

• Do I have a duty to tell the truth? • What is the greater harm? • To whom is my primary loyalty? • What are the best interests of my patient? Framing good ethical questions is the key to strong ethical analysis, and the ability to use a variety of ethical concepts and theories naturally expands the range and quality of questions.

Ethics committees follow 3 distinct models:

•1. autonomy model- facilitate decision making for competent patients. •2. patient-benefit model- what the patient would want if capable of making their wishes known •3. social justice model- board issues and is accountable to the overall institution

paternalism

•Allows one person to make decisions for another •Example: •Can be positive or negative (Career moves)

Ask yourself:

•Am I ever justified in withholding the truth from a patient? •Should I respect the wishes of the family or wishes of the patient? •Is there a point at which the treatment I am providing causes more harm than good? •What do di do when I suspect my best friend is diverting drugs from patients? •Is there a limit to how many scarce resources I should provide to any one patient? •In the mist of covid-19, who gets the ventilators?

Incompetence among peers

•Another dilemma involving nursing ethics is when a nurse notes incompetence in a fellow health care team member and struggles with speaking up or staying silent, said Sarah Delgado, RN, MSN, ACNP, clinical practice specialist with AACN. •"They may feel the behavior should be reported because of the threat to patient safety but hesitate to do so because it would worsen inadequate staffing," Delgado said. "Some dilemmas can be framed as competing obligations, such as protecting the patient on one hand and protecting the staff on the other. The principles to consider are nonmaleficence and fidelity. •Resolving what appear to be competing obligations often requires thinking creatively, Delgado added. •"Solutions often become apparent when we stop and consider all the possible actions available to us," she explained. "Beyond report or don't report, there may be an option to talk to the individual in question, assess his or her awareness of the incompetence, and encourage further training, education or practice.

Disclosing medical conditions

•Another example of an ethical dilemma is telling the truth to a patient vs. being deceptive, Altman said. •"Sometimes families request that patients not be told about their medical condition or diagnosis," Altman added. "The nurse must consider the patient's right to know. How does the nurse know what the family is saying is true?" •The nurse has an obligation to the patient and the ethical principles of nonmaleficence and fidelity—the obligation to prevent harm and the obligation to be faithful to your colleagues, Altman said, adding, "The nurse's own value of truth telling must also be considered."

Informed consent

•Concerns that patients and their families have not been fully informed about their treatments or clinical prognosis is a common ethical concern of nurses, Ulrich reported. •"It can create great concern for nurses," Ulrich said. "Patients feel more comfortable asking the nurse to decipher what was said [by the doctor]. But it's an ethical issue about how much they should convey." •This is especially true about end-of-life decision making, she said. But nurses may not be prepared to have this discussion. She suggested building stronger interdisciplinary teams.

Ask yourself...

•Do I have a duty to tell the truth? •What is the greater harm? •To whom is my primary loyalty? •What are the best interests of my patient?

Autonomy

•Personal freedom and self determination, the right to chose what will happen to oneself as well as the accountability for making individual choices. Self-determination/management. Examples: •Informed consent •Progressive discipline •Being a patient advocate

Beneficence

•Promote good; obligation to assist others. Example: •Taking on more responsibilities at work to assist others

Respect for persons

•Right of individuals to make decisions and to live by these decisions. Example: •Code of ethics

veracity

•Telling the truth Example: •Giving all the facts; good and bad about a job promotion

justice

•Treating all people equally and fairly Example: When deciding who to float to another unit

I'm in an ethical dilemma now what?

•What are the intended outcomes? •What resources are available? •Professional organizational directives? •Examine the likely and unintended consequences