Post on 03-Apr-2018
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Ethical Concerns in Nursing Practice
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Learning outcomes
Discuss the concepts of ethics and morality and theirapplication in the health care field
Describe some ethical theories that may be used to
guide ethical decision-making
identify factors that affect ethical decision-making Analyze ways in which sociocultural and occupational
factors affect ethical decision-making for nurses
Outline a framework for ethical decision-making
Discuss how ethics relates to commitments to thepatient, commitment to personal excellence, and
commitment to nursing as a profession
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Values, Morals, & Ethics
Values: are freely chosen, enduring beliefs or
attitudes about the worth of a person, object,idea, or action (e.g. freedom, family, honesty,
hard work)
Valuesfrequently derive from a persons
cultural, ethnic, and religious background;from societal traditions; and from the values
held by peer group and family
Valuesform a basic for Behaviour purposive
Behaviour; The purposive behavior is basedon a persons decisions/choices, and these
decisions/choices are based on the persons
underlying values.
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Values are learned and are greatly
influenced by a persons sociocultural
environment (e.g. demonstrate honesty,folk healer, observation and experience)
People need societal values to feel
accepted, and they need personal values
to produce a sense of individuality.
Professional values often reflect and
expand on personal values
Once a person becomes aware of his/her
values, they become an internal control for
behavior, thus, a persons real values are
manifested in consistent pattern of
behavior
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Nurses acquire these values during
socialization into nursing from codes of
ethics, nursing experiences, teachers, andpeers.
Watson (1981) outlined 4 important values
of nursing:
Strong commitment to service Belief in the dignity and worth of each
person
Commitment to education
Autonomy nurses often need to behave in a value-
natural way (i.e. being nonjudgmental)
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Nurses need to understand their own values
related to moral matters and to use ethical
reasoning to determine and explain their moral
positions.
Moral principles are also important, otherwise, they
may give emotional responses which often are not
helpful.
Although nurses can not and should not ignore or
deny their own and the professions values, theyneed to be able to accept a clients values and
beliefs rather than assume their own are the right
ones
This acceptance and nonjudgmental approach
requires nurses to be aware of their own valuesand how they influence behavior
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What values you hold about life, health,
illness, and death.
How do your values influence the nursingcare you provide?
We should explore our own values and
beliefs regarding such situations as the
following: An individuals right to make decisions for
self when conflicting with medical advice
Abortion
End-oflife issues Cloning
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The process of becoming more conscious
of and naming what one values or
considers worthy is known as valueclarification
In value clarification:
we examine what we believe is good,
bad, beautiful, worthy, meaningful,..and explore the process of
determining our personal values.
Why?
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Facts vs. Values:
Factual Statement: scientists often perform
painful experiments on animals.
Value Statement: it is morally acceptable(morally required, morally wrong) for us to
perform painful experiments on animals.
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Factual Statement: We created and used
the atomic bomb.
Value Statement: Creating and using the
atomic bomb was morally right (morally
wrong).
Factual statement: someday we will have
the technology to clone human beings.
Value statement: It is morally acceptable
(unacceptable) to clone human beings
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Factual Statement: scientists often perform
painful experiments on animals.
Value Statement: it is morally acceptable(morally required, morally wrong) for us to
perform painful experiments on animals.
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The purposes of value clarifications
This increase our self-awareness or
understanding of ourselves and assist us inmaking choices.
It facilitates decision-making, because wehave a better grasp of our own valuesystem.
Consequently, this will be helpful when youare faced with an ethical dilemma
Ethical dilemma occurs when an individual
must choose between two unfavorablealternatives e.g. assisted suicide
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Helping clients identifying their
values
List alternatives
Examine possible consequences of choices
Choose freely
Feel good about the choice
Affirm the choice
Act on the choice
Act with a pattern
Remember: never impose your personal valuesnever offer an opinion
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Morals and Ethics
Morals: is similar to ethics and many
people use the two wards interchangeably(closely associated with the concept of
ethics)
Derived from the Latin mores, means
custom or habit.
Morality: usually refers to an individuals
personal standards of what is right and
wrong in conduct, character, and attitude.
Morals: are based on religious beliefs and
social influence and group norms
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Morals and Ethics (continue)
Ethics is a branch of philosophy (the
study of beliefs and assumptions)referred to as moral philosophy.
Derived from the Greek word ethos
which means customs, habitual usage,
conduct and character.
Ethics: usually refers to the practices,
beliefs, and standards of behavior of a
particular group such as nurses. It also
refers to the method of inquiry that
assists people to understood the morality
of human behavior (study of morality)
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Morals and Ethics (continue)
In both, we describe the behavior we
observe as good, right, desirable,honorable, fitting or proper or we might
describe the behavior as bad, wrong,
improper, irresponsible, or evil.
[Such perceptions are based on values]
There are times when a differences in
values and decisions can be accepted
Differences in values and decisions put
people into direct conflict.
What to do in such situation?
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Morals and Ethics (resolving conflicts)
Be constructive (rather than destructive) in
the methods you choose to work towardresolving the differences
Listen carefully without interruptions
Seek clarification using gentle questioning
Respect cultural differences Be attentive to body language
Explain the context of your point of view
and try to picture the other persons
expective of what you are saying
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Comparison of morals and ethics
Morals
Principles and rules of right
conduct
Private, and personal
Commitment to principles
and values is usually
defended in daily life
Pertain to an individualscharacter
Ethics
Formal responding process usedto determine right conduct
Professionally and publicly
stated
Inquiry or study of principles and
values
Process of questioning, and
perhaps changing, ones morals
Speaks to relationships between
human beings
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Moral development
Moral development is a complex process
that is not fully understood It is the process of learning what ought to
be done and what ought not to be done
Different approaches to moral
development exists: Kohlbergs theory
Gilligan
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Moral distress
When the nurses are unable to follow their
moral beliefs because of institutional or
other restriction.
The distress occurs when the nurse
violates a personal moral value and fails to
fulfill perceived responsibility.
Moral distress represent practical, rather
than ethical dilemmas.
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Moral outrage
- Occurs when someone else in the health
care setting performs an act the nurse
believes to be immoral.
- Nurses do not participate in the act.
- Nurses not responsible for wrong but
perceive that they are powerless to
prevent.
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Kohlberg Approach
Directly affected by Piagets theory of cognitive
development
Focuses on the structure of though about moral
issues rather than the specific content of moral
values.
Emphasizes fairness, rights and autonomy in ajustice framework
Moral development progresses through three levels:
Level I: premoral or preconventional level
Level II: conventional level
Level III: post conventional, autonomous orprincipled level
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Gilligans theory
Focuses on a care perspectives
Organized around the notions ofresponsibility, compassion (care),relationships
The ethics of justice (fairness) is based ofthe idea of equality everyone shouldreceive the same treatment. By contrast,the ethics of care is based on a premiseof nonviolence: that no one should beharmed or abandoned
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Gilligans theory (continue)
Process of developing an ethics of care
Stage I: caring for oneself
Stage II: caring for others
Stage III: caring for oneself and others
Each stage ends with a transitional period (a
time when the individual recognizes a
conflict or discomfort with some present
behavior and considers new approaches)
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Basic ethical concepts
1. Rights2. Autonomy
3. Beneficence and Nonmaleficence
4. Justice
5. Fidelity6. Veracity
7. The standard of best interest
B i thi l t
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Basic ethical concepts
Rights
Rights form the basis of most professionalcodes and legal judgments
Self-determination rights
Rights and cultural relativism
Rights of the unborn
Rights of privacy and confidentiality
B i thi l t
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Basic ethical concepts
Autonomy
Involves the right of self-determination,independence, and freedom.
It refers to the right to make ones owndecisions
Respect for autonomy means that nurses
recognize the individuals uniqueness,the right to be what that person is, andthe right to choose personal goals
Nurses who follow the principle ofautonomy respect a client's right to make
decisions even when those choicesseem not to be in the clients bestinterest
B i thi l t
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Basic ethical concepts
Autonomy.. (continue)
Respect for people also means treatingothers with consideration
In the clinical setting, this principle is
violated when a nurse disregards client's
subjective accounts of their symptoms(e.g. pain)
Patients should give informed consent
before tests and procedures are carried
out
B i thi l t
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Basic ethical concepts
Beneficence and Nonmaleficence
Beneficence: means doing good Nurses should implement actions that benefit
clients and their support persons. However, in anincreasing technologic health care system, doinggood can also pose a risk of doing harm (e.g.intensive exercise program).
Nonmaleficence: means the duty to do no harm. This is the basic of most codes of nursing ethics.
Harm can mean deliberate harm, risk of harm, andunintentional harm.
In nursing, intentional harm is alwaysunacceptable.
The risk of harm is not always clear A client may be at risk of harm during a nursing
intervention that is intended to be helpful (e.g.medication)
Basic ethical concepts
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Basic ethical concepts
Justice
Is often referred to as fairness Nurses frequently face decisions in
which a sense of justice should prevail
(succeed)
E.g. busy unit, new admission
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Basic ethical concepts
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Basic ethical concepts
Verasity
Refers to telling the truth As a nurse should I tell the truth when it
is known that doing so will cause harm?
Does tell a lie when it is known that the
lie will relieve anxiety and fear? Should I lie to dying people?
Basic ethical concepts
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Basic ethical concepts
The standard of best interest
Applied when a decision must be madeabout a patients health care and the
patient is unable to make an informed
decision
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Ethical theory
An ethical theory provides a
framework within which agents can
reflect on the acceptability of
actions and can evaluate moral
judgments and moral character
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Ethical theories
1- Teleology
2- Deontology
3- Institutionism
4- Ethic of caring
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Ethical theories..(continue)
Example:
Teleology approach/abortion: saving the
mothers life (the end, or consequence)
justifies the abortion (the mean, or act)
Deontology approach/abortion: consider
any termination of life as a violation ofthe rule do not kill and therefore, would
not abort the fetus, regardless of the
consequences to the mother
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Ethical theories..(continue)
Institutionism: summarized as the notion that
people inherently know what is right orwrong; determining what is right is not a
matter or rational thought or learning (e.g.
the nurse inherently knows it is wrong to
strike a client, the nurse does not need tobe taught this or to reason it out)
The preceding three theories are based on the
concept of fairness (justice)
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Ethical theories..(continue)
Ethic of caring: it is based on relationships.
Caring is a force for protecting and
enhancing client dignity
Caring is of central importance in the client-
nurse relationship (e.g. nurses use trust-
telling to affirm clients as a persons ratherthan objects and to assist them to make
choices and find meaning in their illness
experiences)
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Guidelines for Ethical Reasoning
Stay open-minded. Challenge your own views. Its
not enough just to hold a position, you must be able
to support it with good reasons.
Challenge the views of others if you disagree with
them, but do so respectfully and considerately.
Philosophical discussion loses most of its value if
its used as a place to dominate or show off.
Philosophical discussion is best done as a
community enterprise, where all the discussants
work together to get closer to the truth.
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Nursing Codes of Ethics
A code of ethics is a formal statement of a
groups ideals and values. It is a set of ethical principles that is shared by
members of the group, reflects their moral
judgments over time and serves as a standard
for their professional actions.
Codes of Ethics are usually higher than legalstandards
International, national, state nursing associations
have established codes of ethics
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Nursing Codes of Ethics (purposes)
1. To inform the public about the minimum standards of
the profession and to help them understandprofessional nursing conducts
2. To provide a sign of the professions commitment to
the public it serves
3. To outline the major ethical considerations of theprofession
4. To provide general guidelines for professional behavior
5. To guide the profession in self-regulation
6. To remind nurses of the special responsibility theyassume when caring for clients.
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Nursing Codes of Ethics (elements)
Nurses have four fundamental
responsibilities: to promote health, to prevent
illness, to restore health, and alleviate
suffering.
Nurses and people
Nurses and practice
Nurses and the profession
Nurses and the co-workers
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What is Ethical Decision Making?
When faced with an ethical dilemma the
objective is to make a judgment based on
well-reasoned, defensible ethical
principles.
The risk is poor judgment i.e. a low-qualitydecision
A low-quality decision can have a wide
range of negative consequences
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Two Types of Ethical Choices
Right vs wrong: choosing right from wrong
is the easiest
Right vs right
Situation contains shades of gray i.e. all
alternative have desirable and
undesirable results
Choosing the lesser of two evils
Objective: make a defensible decision
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Factors that influence EDM
1. Codes for Nurses
2. The patients rights
3. Social and cultural attitudes
4. Science and technology
5. Legislation6. Judicial decisions
7. Funding
8. Personal religious and philosophic viewpoint
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Factors in the work environment that
affect EDM
1. Status as an employment
2. Collective bargaining contracts
3. Collegial relationships
4. Authoritarian and paternalisticbackground
5. Ethics committees in health care
6. Consumer involvement in health care
A framework for Ethical Decision
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A framework for Ethical Decision
Making (EDM)
1. Identify and clarify the ethical problem
2. Gather data
3. Identify options
4. Make a decision
5. Act and assess
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Making Moral Decisions--Some
Inappropriate Ways:
Appeal to Authority
Appeal to Law
Appeal exclusively to self-interest
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Some Guidelines for Making
Ethical Decisions
1. Choose correct moral language.(Often, the
way in which you initially
conceptualize a situation will affect
what moral conclusions you will make)
2. Be as clear as you can about the facts,
both empirical and philosophical
3. Consider the relevant moral principles and
rules, and make your best judgment.
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Ethics Committees
With the increasing complexity of ethical issues in
health care, ethics committees have been created
to assist in making ethical decisions in clinical
settings. Ethical committees can:
1. Provide structure and guidelines for potential
problems.
2. Serve as an open forum for discussion and debate.
3. Function as a patient advocate by placing the
patient at the core of the committees deliberations.
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Case Studies
Mrs. C., an 85-year-old woman with
severe emphysema, is found
unresponsive by her husband. He calls
for an ambulance. Emergency medical
personnel perform endotrachealintubation and resuscitate her
successfully. She then is taken to the
local hospital for treatment of
pneumonia and respiratory failure.After treatment for her medical
conditions, she cannot be weaned from
the respirator.
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The patient is able to communicate her
wishes by using head signals and
writing notes. After several weeks of
treatment, she asks that the respirator
be discontinued and she be allowed todie. Mrs. C. asserts emphatically that
she would not have wanted to be
resuscitated in the first place, although
she never executed an advanceddirective or discussed these specific
wishes with anyone.
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Discussion Questions
Is the patients decision a rational one?
What is the difference between withholdingand withdrawing life-sustaining treatment?
In view of the fact that a potent sedative
such as morphine may produce respiratorydepression, should this be given prior todiscontinuing the respirator? Would thisconstitute active euthanasia?
Would the situation be different if Mrs. C.
had a living will? What role could the nurse play in
addressing the ethical issues in this case?
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Living Wills
Prepared while patient has decisional capacity
Describes patient preferences in the event they
become incapable of making decisions orcommunicating decisions.
Usually describes what type of life prolonging
procedures the patient would or would notwant and circumstances under which theywould want these procedures carried out,withheld, or withdrawn