Values, Ethics, and Advocacy - Chapter 5 - Module

Morality vs. Law

laws reflect the moral values of a society, and they offer guidance in determining what is moral. An action can be legal but not moral.

consequence-based (telological) theories

look to the outcomes (consequences) of an action in judging whether that action is right or wrong.

List alternatives

make sure that the client is aware of all alternative actions. Ask: "are you considering other courses of action?" "Tell me about them"

Beneficence

means "doing good." Nurses are obligated to do good, that is, to implement actions that benefit clients and their support persons.

Fidelity

means to be faithful to agreements and promises. Nurses often make promises such as "I'll be right back with your pain medication" or "I'll find out for you." Clients take such promises seriously, and so should nurses.

Passive Euthanasia

more commonly referred to as withdrawing or withholding life-sustaining therapy, involves the withdrawal of extraordinary means of life support, such as removing a ventilator or withholding special attempt to revive a client (e.g. giving the client "no code" status) and allowing the client to die of the underlying medical condition.

Utilitarianism

one form of consequentialist theory, views a good act as one that is most useful- that is, one that brings the most good and the least harm to the greatest number of people. This is called the principle of utility.

Value System

people organize their values internally along a continuum from most important to least important, forming a value system. They form the basis of behavior.

Nursing Ethics

refers to ethical issues that occur in nursing practice.

Autonomy

refers to the right to make one's own decisions. Nurses who follow this principle recognize that each client is unique, has the right to be who that individual is, and has the right to choose personal goals. Honoring the principle of autonomy means that the nurse respects a client's right to make decisions even when those choices seem to the nurse not to be in the client's best interest.

relationships-based (caring) theories

stress courage, generosity, commitment, and the need to nurture and maintain relationships. Caring theories judge actions according to a perspective of caring and responsibility. They promote the common good or the welfare of the group.

Moral Development

the process of learning to tell the difference between right and wrong or learning what ought and ought not to be done. It is a complex process that begins in childhood and continues throughout life.

Professional Responsibility

the specific accountability or liability associated with the performance of duties of a particular role

Clarifying Client Values

to plan effective client-centered care, nurses need to identify client's values as they influence and relate to a particular health problem. If clients appear to hold unclear or conflicting values that are detrimental to their health, the nurse should use values clarification as an intervention. The following process may help clients clarify their values: 1. list alternatives 2. examine possible consequences of choices 3. choose freely 4. feeling about the choice 5. affirm the choice 6. act with a pattern

Morality

usually refers to private, personal, standards of what is right and wrong in conduct, character, and attitude. Moral issues are concerned with important social values and norms; they are not about trivial things.

Values Transmission

values are learned through observation and experience. As a result, they are heavily influenced by a person's sociocultural environment, i.e. by societal traditions, by cultural, ethnic, and religious groups, and by family and peer groups.

Ethical behavior is contextual

what is an ethical action or decision in one situation may not be ethical in a different situation

Bioethics

ethics as applied to human life or health e.g. decisions about abortion or euthanasia

Teleological theories focus on issues of

fairness

principles-based (deontological) theories

involve logical and formal processes and emphasize individual rights, duties, and obligations. The morality of an action is determined not by its consequences but by whether it is done according to an impartial, objective principle. For example, following the rule "do not lie", a nurse might believe he or she should tell the truth to a dying client, even though the physician has given instructions not to do so. Each deontological theories justifies the rules of acceptable behavior. They stress individual rights.

Active Euthanasia

involves actions to bring about the client's death directly, with or without client consent. Regardless of the caregiver's intent, active euthanasia is forbidden by law and can result in criminal charges of murder.

Altruism

is a concern for the welfare and well-being of others. In professional practice, altruism is reflected by the nurses's concern for the welfare of patients, other nurses, and other health care providers.

Code of Ethics

is a formal statements of a groups' ideals and values. It is a set of ethical principles that a. is shared by members of the group b. reflects their moral judgements over time c. serves as a standard for their professional actions. Codes of ethics usually have higher requirements than legal standards, and they are never lower than the legal standards of the profession.

Values Clarification

is a process by which people identify, examine, and develop their own individual values. A principle of values clarification is that no one set of values is right for everyone. When people can identify their values, they can retain or change them and thus act based on freely chosen, rather than unconscious, values. It promotes personal growth by fostering awareness, empathy, and insight.

Integrity

is acting in accordance with an appropriate code of ethics and accepted standards of practice. Integrity is reflected in professional practice when the nurse is honest and provides care based on an ethical framework that is accepted within the profession.

Social Justice

is acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability, or sexual orientation.

Justice

is frequently referred to as fairness. Nurses often face decisions in which a sense of justice should prevail.

Advocate

is one who expresses and defends the cause of another. Today, clients are seeking more self-determination and control over their own bodies. If a client lacks decision-making capacity, is legally incompetent, or is a minor, these rights can be exercised on the clients behalf by a designated surrogate or proxy decision maker. The nurse must ascertain the client's and family's views and honor their traditions regarding the locus of decision making.

Human Dignity

is respect for the worth and uniqueness of individuals and populations. In professional practice, human dignity is reflected when the nurse values and respects all patients and colleagues.

Beliefs

(or opinions) are interpretations or conclusions that people accept as true. They are based more on faith than fact, and do not necessarily involve values.

Box 5-6 The Basics to Client Advocacy

*The client is a holistic, autonomous being who has the right to make choices and decisions. *Clients have the right to expect a nurse-client relationship that is based on shared respect, trust, collaboration in solving problems related to health and health care needs, and consideration of their thoughts and feelings. *It is the nurse's responsibility to ensure the clients has access to health care services that meet health needs.

Nursing codes of ethics have the following purposes:

1. Inform the public about the minimum standards of the profession and help them understand professional nursing conduct. 2. Provide a sign of the profession's commitment to the public it serves. 3. Outline the major ethical considerations of the profession. 4. Provide ethical standards for professional behavior. 5. Guide the profession in self-regulation. 6. Remind nurses of the special responsibility they assume when caring for the sick.

Abortion

Abortion is a highly publicized issue about which many people feel very strongly. Debate continues, pitting the principle of sanctity of life against the principle of autonomy and a woman's right to control her own body. This is an especially volatile issue because no public consensus has yet been reached. Most state laws have provisions known as conscience clauses that permit individual primary care providers and nurses, as well as institutions, to refuse to assist with an abortion if doing so violates their religious or moral principles. However, nurses have no right to impose their values on a client. Nursing codes of ethics support clients' right to information and counseling in making decisions.

Conflicting Loyalties and Obligations

According to the nursing code of ethics, the nurses's first loyalty is to the client. However, it is not always easy to determine which action best serves the client's needs.

Specific Ethical Issues

Acquired Immunodeficiency Syndrome (AIDS) Abortion Organ and Tissue Transplantation End-of-Life Issues Advance Directives Euthanasia and Assisted Suicide Termination of Life-Sustaining Treatment Withdrawing or Withholding Food and Fluids Allocation of Scarce Health Resources Management of Personal Health Information

Professional and Public Advocacy

Advocacy is needed for the nursing profession as well as for the public. Gains that nursing makes in developing and improving health policy at the institutional and government levels help to achieve better health care for the public. Nurses who function responsibly as professional and public advocates are in a position to effect change. To act as an advocate in this arena, the nurse needs an understanding of the ethical issues in nursing and health care, as well as knowledge of the laws and regulations that affect nursing practice and the health of society.

Allocation of Scarce Health Resources

Allocation of limited supplies of health care goods and services, including organ transplants, artificial joints, and the services of specialists, has become an especially urgent issue as medical costs continue to rise and more stringent cost-containment measures are implemented. In this situation, health care providers may use the principe of justice - attempting to choose what is most fair to all. Nursing care is also a health resource. California is the first state to enact legislation mandating specific nurse-to-client ratios in hospitals and other health care settings. With a nationwide shortage of nurses, an ethical dilemma arises when, in order to provide adequate staffing, facilities must turn away needy clients. Nurses must continue to look for ways to balance economics and caring in the allocation of health resources.

Advocacy in Home Care

Although the goals of advocacy remain the same, home care poses unique concerns for the nurse advocate. For example, while in the hospital, people may operate from the values of the nurses and primary care providers. When they are at home, they tend to operate from their own personal values and may revert to old habits and ways of doing things that may not be beneficial to their health. The nurse may see this as noncompliance; nevertheless, client autonomy must be respected. Financial considerations can limit the availability of services and materials, making it difficult to ensure that client needs are met.

Nonmaleficence

is the duty to "do no harm." Although this would seem to be a simple principle to follow, in reality it is complex. Harm can mean intentionally causing harm, placing someone at risk of harm, and unintentionally causing harm. In nursing, intentional harm is never acceptable.

Autonomy

is the right to self-determination. Professional practice reflects autonomy when the nurse respects patients' rights to make decisions about their health care.

Affirm the Choice

Ask "How will you discuss this with others (friends, family)?"

Acquired Immunodeficiency Syndrome (AIDS)

Because of its association with sexual behavior, illicit drug use, and physical decline and death, AIDS bears a social stigma. According to the ANA, the moral obligation to care for a client with HIV infection cannot be set aside unless the risk exceeds the responsibility. Other ethical issues center on testing for HIV status for the presence of AIDS in health professionals and clients. Questions arise as to whether testing of all providers and clients should be mandatory or voluntary and whether test results should be released to insurance companies, sexual partners, or caregivers.

Termination of Life-Sustaining Treatment

Clients may specify that they wish to have life-sustaining measures withdrawn, they may have advance directive on this matter, or they may appoint a surrogate decision maker. However, it is usually more troubling for health care professional to withdraw a treatment than to decide initially not to begin it. Nurses must understand that a decision to withdraw treatment is not a decision to withdraw care. It is difficult for families to withdraw treatment, which makes it very important that they fully understand the treatment. They often have misunderstandings about which treatments are life sustaining. Keeping clients and families well informed is an ongoing process, allowing them time to ask question and discuss the situation. It is also essential that they understand that they can reevaluate and change their decision if they wish.

Organ and Tissue Transplantation

Ethical issues related to organ transplantation include allocation of organ, selling of body parts, involvement of children as potential donors, consent, clear definition of death, and conflicts of interest between potential donors and recipients. In some situations, a person's religious belief may also present conflict. For example, certain religious forbid the mutilation of the body, even for the benefit of another person. Individuals' spiritual beliefs and views on when human life begins have an impact on their opinions about stem cell research. The ANA supports the ethical use of stem cells for research and therapeutic purposes that impact health.

Nursing Ethics

Ethical standards of the Joint Commission mandate that health care institutions provide ethics committees or a similar structure to write guidelines and policies and to provide education, counseling, and support on ethical issues.

Euthanasia and Assisted Suicide

Euthanasia means "good death" and is popularly known as a "mercy death"

Management of Personal Health Information

In keeping with the principle of autonomy, nurses are obligated to respect clients' privacy and confidentiality. Privacy is both a legal and ethical mandate. HIPPA includes standards protecting the confidentiality, integrity, and availability of data, and standards defining appropriate disclosures of identifiable health information and client rights protection. Clients must be able to trust that nurses will reveal details of their situation only as appropriate and will communicate only the information necessary to provide for their health care.

Withdrawing or Withholding Food and Fluids

It is generally accepted that providing food and fluids is part of ordinary nursing practice and, therefore, a moral duty. A nurse is morally obligated to withhold food and fluids (or any treatment) if it is determined be more harmful to administer them than to withhold them. The nurse must also honor competent and informed clients' refusal of food and fluids. The ANA Code of Ethics for Nurses supports this position through the nurse's role as a client advocate and through the moral principle of autonomy.

Examine Possible Consequences of Choices

Make sure the client has thought about possible results of each action. Ask "What do you thing you will gain from doing that?" "What benefits do you foresee from doing that?"

Advance Directives

Many moral problems surrounding the end of life can be resolved if clients complete advance directives which direct caregivers as to the client's wishes about treatments, providing an ongoing voice for clients when they have lost the capacity to make or communicate their decisions.

Making Ethical Decisions

Many nursing problems are not moral problems at all, but simply questions of good nursing practice. Responsible ethical reasoning is rational and systematic. It should be based on ethical principles and codes rather than on emotions, intuition, fixed policies, or precedent. Each institution adopts its own set of steps for making formal ethical decisions, but each nurse also benefits from having an organizing framework for analyzing ethical issues.

Moral Principles

Moral principles are statements about broad, general, philosophical concepts such as autonomy and justice. They provide the foundation for moral rules. moral rules autonomy nonmaleficence beneficence justice fidelity professional accountability professional responsibility

Moral Frameworks

Moral theories provide different frameworks through which nurses can view and clarify disturbing client care situations. Nurses can use moral theories in developing explanations for their ethical decisions and actions and in discussing problem situations with others. Moral frameworks guide moral decisions, but do not determine the outcome.

Origins of Ethical Problems in Nursing

Nurse's growing awareness of ethical problems has occurred largely because of a. social and technologic changes b. nurses' conflicting loyalties and obligations

Clarifying the Nurse's Values

Nurses hold both personal and professional values. As is true with all people, nurses' values are influenced by culture, education, and age. However, research shows that fundamental professional nursing values of *human dignity, equality, and prevention of suffering* have not varied over time or across groups.

Social and Technologic Changes

Social changes, such as the women's movement and a growing consumerism, also expose problems. The large number of people without health insurance, the high cost of health care, and workplace redesign under managed care all raise issues of fairness and allocation of resources. Advances in the ability to decode and control growth of tissues their gene manipulation present new potential ethical dilemmas related to cloning organisms and altering the course of hereditary diseases and biologic characteristics.

Strategies to Enhance Ethical Decisions and Practice

Several strategies help nurses overcome possible organizational and social constraints that may hinder the ethical practice of nursing and create moral distress for nurses. You as a nurse should do the following: *Become aware of your own values and the ethical aspects of nursing *Be familiar with nursing codes of ethics. *Seek continuing education opportunities to stay knowledgable about ethical issues in nursing. *Respect the values, opinions, and responsibilities of other healthcare professionals that may be different from your own. *Participate in or establish ethics rounds. Ethics rounds use hypothetical or real cases that focus on the ethical dimensions of client care rather than the client's clinical diagnosis and treatment. *Serve on institutional ethics committees. *Strive for collaborative practice in which nurses function effectively in cooperation with other health care professionals.

Feeling About the Choice

Some clients may not feel satisfied with their decision.

Method to assist nurses in coping with moral distress is

The 4A's to Rise Above Moral Distress: Using this model, the nurse ASKS whether signs of moral distress are present, AFFIRMS a commitment to addressing the distress, ASSESSES the sources and severity of the distress plus readiness to act, and ACTS to implement a plan to reduce the distress.

End-of-Life Issues

The increase in technologic advances and the growing number of older adults have expanded ethical dilemmas. Some of the most frequent disturbing ethical problems for nurses involve issues that arise around death and dying. These include euthanasia, assisted suicide, termination of life-sustaining treatment, and withdrawing or withholding of food and fluids.

Moral Distress

The nurse may feel torn between obligations to the client, family, and the employer. What is in the client's best interest may be contrary to the nurse's personal belief system. This conflict is referred to as moral distress and is considered a serious issue in the workplace.

The Advocate's Role

The overall goal of the client advocate informs clients about their rights and provides them with the information they need to make informed decisions. Advocacy requires accepting and respecting the clients' right to decide, even if the nurse believes the decision is wrong.

Ethics

The term ethics has several meanings in common use. It refers to a. the method of inquiry that helps people to understand the morality of human behavior (i.e. it is the study of morality) b. the practices or beliefs of a certain group (e.g. medical ethics, nursing ethics) c. the expected standards of moral behavior of a particular group as described in the group's formal code of precessional ethics.

Choose Freely

To determine whether the client chose freely, ask "Did you have any say in that decision?" "Do you have a choice"

Act with a Pattern

To determine whether the client consistently behaves in a certain way, ask "how many times have you done that before?" or "would you act that way again?"

Principle of Utility

brings the most good and the least harm to the greatest number of people. This approach is often used in making decisions about the funding and delivery of health care.

Assisted Suicide

a variation of active euthanasia. Giving the client the means to kill themselves if they request it (e.g. providing lethal doses of pills). The ANA's position statement on assisted suicide and active euthanasia states that both are in violation of the Code of Ethics for Nurses

Three types of moral theories are widely used, and they can be differentiated by their emphasis on:

a. consequence-based (theological) theories b. principles-based (deontological) theories c. relationships-based (caring) theories

In their daily work, nurses deal with intimate and fundamental human events such as birth, death, and suffering. Therefor, nurses need to:

a. develop sensitivity to the ethical dimensions of practice b. examine their own and client's values c. understand how values influence their decisions d. think ahead about the kinds of moral problems they are likely to face

Personal Values

although people derive values from society and their individual subgroups, they internalize some or all of these values as personal values. People need societal values to feel accepted, and they need personal values to have a sense of individuality.

Professional Accountability

answerable to oneself and others for one's own actions

Professional Values

are acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers. The ANA identified five values essential for the professional nurse: altruism, autonomy, human dignity, integrity, and social justice.

Values

are enduring beliefs or attitudes about the worth of a person, object, idea, or action. Values are important because they influence decisions and actions, including nurses' ethical decision making.

Attitudes

are mental positions or feelings toward a person, object, or idea (e.g. acceptance, compassion, openness). Typically, an attitude lasts over time, whereas a belief may last only briefly.

Moral Rules

are specific prescriptions for actions.