Ethical Foundation 4

7/28/2019 Ethical Foundation 4

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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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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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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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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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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)



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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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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?



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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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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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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

Ethical Foundation 4

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