10. Ethical Concerns in Nursing Practice

8/16/2019 10. Ethical Concerns in Nursing Practice

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Ethical Concerns in Nursing

Practice



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Values, Morals, & Ethics

• Values: are freely chosen,

enduring beliefs or attitudesabout the worth of a person,object, idea, or action e!g!freedo", fa"ily, honesty, hardwor#$

• Values fre%uently derie fro" a

person's cultural, ethnic, andreligious bac#ground( fro"societal traditions( and fro" thealues held by peer group andfa"ily

• Values for" a basic for)ehaiour *purposie)ehaiour+( he purposiebehaior is based on a person'sdecisions-choices, and thesedecisions-choices are based on

the person's underlying alues!



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• Values are learned and are greatlyinfluenced by a person's

sociocultural eniron"ent e!g!de"onstrate honesty, fol# healer,obseration and e.perience$

• People need societal alues to feelaccepted, and they need personal

alues to produce a sense ofindiiduality!

• Professional alues often reflect ande.pand on personal alues

• /nce a person beco"es aware ofhis-her alues, they beco"e aninternal control for behaior, thus, aperson's real alues are "anifestedin consistent pattern of behaior



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• Nurses ac%uire these aluesduring sociali0ation into nursing 1

fro" codes of ethics, nursinge.periences, teachers, and peers!

• 2atson 3453$ outlined 6i"portant alues of nursing:

• 7trong co""it"ent to serice

• )elief in the dignity and worthof each person

• Co""it"ent to education

• 8utono"y

• nurses often need to behae in aalue9natural way i!e! beingnonjudg"ental$



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• Nurses need to understand their own

alues related to "oral "atters and

to use ethical reasoning to deter"ine

and e.plain their "oral positions!

• Moral principles are also i"portant,otherwise, they "ay gie e"otional

responses which often are not

helpful!

• 8lthough nurses can not and should

not ignore or deny their own and theprofession's alues, they need to be

able to accept a client's alues and

beliefs rather than assu"e their own

are the *right ones+

his acceptance and nonjudg"entalapproach re%uires nurses to be

aware of their own alues and how

they influence behaior



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• 2hat alues you hold about life,

health, illness, and death!

• ow do your alues influence thenursing care you proide;

• 2e should e.plore our own alues

and beliefs regarding such situations

as the following:• 8n indiidual's right to "a#e

decisions for self when conflicting

with "edical adice

• 8bortion• End9of 1life issues

• Cloning



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• he process ofbeco"ing "oreconscious of andna"ing what one aluesor considers worthy is#nown as *alueclarification+

• <n alue clarification:we e.a"ine what webeliee is good, bad,beautiful, worthy,"eaningful, =!!and

e.plore the process ofdeter"ining ourpersonal alues!

2hy;



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>acts s! Values:

• >actual 7tate"ent:

scientists often perfor"

painful e.peri"ents on

ani"als!

• Value 7tate"ent: it is

"orally acceptable "orally

re%uired, "orally wrong$ for

us to perfor" painful

e.peri"ents on ani"als!



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• >actual 7tate"ent: 2ecreated and used theato"ic bo"b!

• Value 7tate"ent:Creating and using theato"ic bo"b was "orallyright "orally wrong$!

• >actual state"ent:so"eday we will haethe technology to clonehu"an beings!

• Value state"ent: <t is"orally acceptableunacceptable$ to clonehu"an beings



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• >actual 7tate"ent: scientists often perfor" painful

e.peri"ents on ani"als!

• Value 7tate"ent: it is "orally acceptable "orally re%uired,

"orally wrong$ for us to perfor" painful e.peri"ents on

ani"als!



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he purposes of alue clarifications

his increase our self9awareness or understanding of

ourseles and assist us in "a#ing choices! <t facilitates decision9"a#ing, because we hae a better

grasp of our own alue syste"!

Conse%uently, this will be helpful when you are facedwith an ethical dile""a

• Ethical dile""a occurs when an indiidual "ustchoose between two unfaorable alternaties *e!g!assisted suicide+



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• Ethical dile""a usually haeno perfect solution and those"a#ing decisions "ay findthe"seles in the position ofhaing to defend their decisions

• Value conflict occurs when we"ust choose between two

things, both of which arei"portant to us!

• <t's the nurses' role to helpclients identify alues and clarifythe"==

)utow;;;;;;



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elping clients identifying their

alues

• ?ist alternaties

• E.a"ine possible conse%uences of choices

• Choose freely

• >eel good about the choice

• 8ffir" the choice

• 8ct on the choice

• 8ct with a pattern

@e"e"ber: neer i"pose your personal aluesneer offer an opinion



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Morals and Ethics

• Morals: is si"ilar to ethics and

"any people use the twowards interchangeably closelyassociated with the concept ofethics$

• Aeried fro" the ?atin

*"ores+, "eans custo" orhabit!

• Morality: usually refers to anindiidual's personal standardsof what is right and wrong inconduct, character, andattitude!

• Morals: are based on religiousbeliefs and social influence

and group nor"s



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Morals and Ethics continue$

• Ethics is a branch of philosophy the study of beliefs and

assu"ptions$ referred to as "oral philosophy!• Aeried fro" the Bree# word *ethos+ which "eans

custo"s, habitual usage, conduct and character!

• Ethics: usually refers to the practices, beliefs, and

standards of behaior of a particular group such asnurses! <t also refers to the "ethod of in%uiry that

assists people to understood the "orality of hu"an

behaior study of "orality$



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Morals and Ethics continue$

• <n both, we describe the behaior we obsere as good,

right, desirable, honorable, fitting or proper or we "ightdescribe the behaior as bad, wrong, i"proper,

irresponsible, or eil!

7uch perceptions are based on aluesD

• here are ti"es when a differences in alues anddecisions can be accepted

• Aifferences in alues and decisions put people into direct

conflict!

2hat to do in such situation;



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Morals and Ethics resoling conflicts$

• )e constructie rather than destructie$ in the "ethods you

choose to wor# toward resoling the differences• ?isten carefully without interruptions

• 7ee# clarification using gentle %uestioning

• @espect cultural differences

• )e attentie to body language

• E.plain the conte.t of your point of iew and try to picture

the other person's e.pectie of what you are saying



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Co"parison of "orals and ethics

Morals

• Principles and rules of right

conduct

• Priate, and personal

• Co""it"ent to principles

and alues is usually

defended in daily life

• Pertain to an indiiduals

character

Ethics

• >or"al responding process used

to deter"ine right conduct

• Professionally and publicly

stated

• <n%uiry or study of principles and

alues

• Process of %uestioning, and

perhaps changing, one's "orals

• 7pea#s to relationships between

hu"an beings



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Moral deelop"ent

• Moral deelop"ent is a co"ple. process that is not

fully understood• <t is the process of learning what ought to be done

and what ought not to be done

• Aifferent approaches to "oral deelop"ent e.ists:

• Fohlberg's theory

• Billigan



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Moral distress

• 2hen the nurses are unable to follow their "oral beliefs

because of institutional or other restriction!• he distress occurs when the nurse iolates a personal

"oral alue and fails to fulfill perceied responsibility!

• Moral distress represent practical, rather than ethical

dile""as!



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Moral outrage

9 /ccurs when so"eone else in the health care setting

perfor"s an act the nurse beliees to be i""oral!9 Nurses do not participate in the act!

9 Nurses not responsible for wrong but perceie that they

are powerless to preent!



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Fohlberg 8pproach

•Airectly affected by Piaget's theory of cognitiedeelop"ent

• >ocuses on the structure of though about "oral

issues rather than the specific content of "oral

alues!

• E"phasi0es fairness, rights and autono"y in a justice fra"ewor#

• Moral deelop"ent progresses through three leels:

• ?eel <: pre"oral or preconentional leel

• ?eel <<: conentional leel

• ?eel <<<: post conentional, autono"ous or

principled leel



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Billigan's theory

• >ocuses on a care perspecties

• /rgani0ed around the notions of responsibility,co"passion care$, relationships

• he ethics of justice fairness$ is based of the idea ofe%uality *eeryone should receie the sa"e treat"ent+!

)y contrast, the ethics of care is based on a pre"ise ofnoniolence: that no one should be har"ed orabandoned



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Billigan's theory continue$

• Process of deeloping an *ethics of care+

• 7tage <: caring for oneself

• 7tage <<: caring for others

• 7tage <<<: caring for oneself and others

• Each stage ends with a transitional period a

ti"e when the indiidual recogni0es a

conflict or disco"fort with so"e present

behaior and considers new approaches$



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Moral-ethical principles concepts$

• 8re state"ents about

broad, generalphilosophic conceptssuch as autono"y and

justice

• hey proide thefoundation for "oralalues, which arespecific prescriptionsfor actions e!g! *people

should not lie+ rule$ isbased on the "oralprinciple of respect ofautono"y for people!



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)asic ethical concepts

3! @ightsG! 8utono"y

H! )eneficence and

Non"aleficence

6! IusticeJ! >idelity

K! Veracity

L! he standard of

best interest



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@ights

• @ights for" the basis of "ostprofessional codes and legal

judg"ents

• 7elf9deter"ination rights

• @ights and culturalrelatiis"

•@ights of the unborn

• @ights of priacy andconfidentiality



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8utono"y

• <noles the right of self9deter"ination,independence, and freedo"!

• <t refers to the right to "a#e one's owndecisions

• @espect for autono"y "eans that nurses

recogni0e the indiidual's uni%ueness,the right to be what that person is, andthe right to choose personal goals

• Nurses who follow the principle ofautono"y respect a clients right to "a#e

decisions een when those choices see"not to be in the client's best interest





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)eneficence and Non"aleficence

Beneficence: "eans *doing good+• Nurses should i"ple"ent actions that benefit

clients and their support persons! oweer, in anincreasing technologic health care syste", doinggood can also pose a ris# of doing har" e!g!intensie e.ercise progra"$!

Nonmaleficence: "eans the duty to do no har"!• his is the basic of "ost codes of nursing ethics!• ar" can "ean deliberate har", ris# of har", and

unintentional har"!• <n nursing, intentional har" is always

unacceptable!• he ris# of har" is not always clear • 8 client "ay be at ris# of har" during a nursing

interention that is intended to be helpful e!g!"edication$



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Iustice

• <s often referred to as fairness• Nurses fre%uently face decisions in which a

sense of justice should preail succeed$

• E!g! busy unit, new ad"ission



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>idelity

• Means to be faithful to agree"ents andresponsibilities one has underta#en

• Nurses hae responsibilities to clients,

e"ployers, goern"ent, society, the

profession, and the"seles• Circu"stances often affect which

responsibilities ta#e precedence at a

particular ti"e



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Verasity

• @efers to telling the truth• 8s a nurse should < tell the truth when it

is #nown that doing so will cause har";

• Aoes tell a lie when it is #nown that the

lie will reliee an.iety and fear;• 7hould < lie to dying people;



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he standard of best interest

• 8pplied when a decision "ust be "adeabout a patient's health care and the

patient is unable to "a#e an infor"ed

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

39 eleology

G9 Aeontology

H9 <nstitutionis"

69 Ethic of caring



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Ethical theories=!continue$

Teleology: loo#s to the conse%uences of an action in judging whether

that action is right or wrong

Deontology: proposes that the "ortality of a decision is notdeter"ined by its conse%uences! <t e"phasi0es duty, rationality,and obedience to rules

he difference between eleology and Aeontology can be seen wheneach approach is applied to the issue of abortion



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Ethical theories=!!continue$

E.a"ple:

eleology approach-abortion: saing the "other's

life the end, or conse%uence$ justifies the

abortion the "ean, or act$

Aeontology approach-abortion: consider any

ter"ination of life as a iolation of the rule *donot #ill+ and therefore, would not abort the fetus,

regardless of the conse%uences to the "other



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Ethical theories=!!continue$

Institutionism: su""ari0ed as the notion that people

inherently #now what is right or wrong( deter"ining whatis right is not a "atter or rational thought or learninge!g! the nurse inherently #nows it is wrong to stri#e aclient, the nurse does not need to be taught this or toreason it out$

he preceding three theories are based on the concept offairness justice$

Ethic of caring: it is based on relationships!

Caring is a force for protecting and enhancing client dignity

Caring is of central i"portance in the client9nurserelationship e!g! nurses use trust9telling to affir" clientsas a persons rather than objects and to assist the" to"a#e choices and find "eaning in their illnesse.periences$



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Buidelines for Ethical @easoning

7tay open9"inded! Challenge your own iews! <t's

not enough just to hold a position, you "ust be

able to support it with good reasons!

Challenge the iews of others if you disagree withthe", but do so respectfully and considerately!

Philosophical discussion loses "ost of its alue if

it's used as a place to do"inate or show off!

Philosophical discussion is best done as a

co""unity enterprise, where all the discussants

wor# together to get closer to the truth!



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Nursing Codes of Ethics

• 8 code of ethics is a for"al state"ent of a group's ideals and alues!

• <t is a set of ethical principles that is shared by "e"bers of thegroup, reflects their "oral judg"ents oer ti"e and seres as a

standard for their professional actions!

• Codes of Ethics are usually higher than legal standards

• <nternational, national, state nursing associations hae established

codes of ethics



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Nursing Codes of Ethics purposes$

3! o infor" the public about the "ini"u" standards of

the profession and to help the" understandprofessional nursing conducts

G! o proide a sign of the profession's co""it"ent to

the public it seres

H! o outline the "ajor ethical considerations of theprofession

6! o proide general guidelines for professional behaior

J! o guide the profession in self9regulation

K! o re"ind nurses of the special responsibility theyassu"e when caring for clients!



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Nursing Codes of Ethics ele"ents$

• Nurses hae four

funda"ental

responsibilities: to pro"ote

health, to preent illness, to

restore health, and alleiate

suffering!

• Nurses and people

• Nurses and practice

• Nurses and the

profession• Nurses and the co9

wor#ers



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2hat is Ethical Aecision Ma#ing;

• 2hen faced with an ethical dile""a the objectie is

to "a#e a judg"ent based on well9reasoned,

defensible ethical principles!

• he ris# is poor judg"ent i!e! a low9%uality decision

• 8 low9%uality decision can hae a wide range of

negatie conse%uences



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wo ypes of Ethical Choices

• @ight s wrong: choosing right fro"

wrong is the easiest

• @ight s right

• 7ituation contains shades of gray

i!e! all alternatie hae desirable

and undesirable results

• Choosing *the lesser of two eils+

• /bjectie: "a#e a defensible

decision



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>actors that influence EAM

3! Codes for Nurses

G! he patient's rights

H! 7ocial and cultural attitudes

6! 7cience and technologyJ! ?egislation

K! Iudicial decisions

L! >unding5! Personal religious and philosophic

iewpoint



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>actors in the wor# eniron"ent that

affect EAM

3! 7tatus as an e"ploy"ent

G! Collectie bargaining contracts

H! Collegial relationships

6! 8uthoritarian and paternalisticbac#ground

J! Ethics co""ittees in health care

K! Consu"er inole"ent in health

care



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8 fra"ewor# for Ethical Aecision

Ma#ing EAM$

3! <dentify and clarify the ethical proble"

G! Bather data

H! <dentify options

6! Ma#e a decision

J! 8ct and assess



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Ma#ing Moral Aecisions997o"e

<nappropriate 2ays:

• 8ppeal to 8uthority

• 8ppeal to ?aw

• 8ppeal e.clusiely to self9interest



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7o"e Buidelines for Ma#ing

Ethical Aecisions

3! Choose correct "oral language!/ften, the way in

which you initially

conceptuali0e a situation will affect

what "oral conclusions you will "a#e$

G! )e as clear as you can about the facts, both e"pirical

and philosophical

H! Consider the releant "oral principles and rules, and

"a#e your best judg"ent!



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Ethics ommittees

2ith the increasing co"ple.ity of ethical issues in health care,

ethics co""ittees hae been created to assist in "a#ing

ethical decisions in clinical settings! Ethical co""ittees

can:

3! Proide structure and guidelines for potential proble"s!

G! 7ere as an open foru" for discussion and debate!

H! >unction as a patient adocate by placing the patient at the

core of the co""ittee's deliberations!



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Aiscussion uestions

• <s the patient's decision a rational one;

• 2hat is the difference between withholding and

withdrawing life9sustaining treat"ent;

• <n iew of the fact that a potent sedatie such as

"orphine "ay produce respiratory depression, should

this be gien prior to discontinuing the respirator;

2ould this constitute actie euthanasia;

• 2ould the situation be different if Mrs! C! had a liing

will;

• 2hat role could the nurse play in addressing the ethical

issues in this case;



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notes

• Euthanasia

Bree# words "eaning *easy death+!

Euthanasia is an act by which the causatie agent of

death is ad"inistered by another with the intent to end

life!

Filling an innocent person, een at his or her re%uest is

not ethical!

*Code for Nurses 345J$ and the 8N8 position state"ent

3446$ states that the nurse should not participate in

euthanasia but be igilant adocates for the deliery of

dignified and hu"an care!



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• Living Wills

Prepared while patient has decisional capacity

Describes patient preferences in the event

they become incapable of making decisions

or communicating decisions.

Usually describes what type of life prolonging

procedures the patient would or would not

want and circumstances under which they

would want these procedures carried out

withheld or withdrawn

Documents

10. Ethical Concerns in Nursing Practice