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- Arts and Humanities
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Terms in this set (116)
gray area
where what are right or wrong acts is not clear or sharply delineated
nursing focuses on human responses
What can help nurses face the complex ethical issues that confront them?
understanding ethical principles, frameworks, nursing's code of ethics, and your own values and beliefs.
ethics
the examination of question of right and wrong
ethics are also known as
"moral philosophy"
3 types of ethics
metaethics, normative ethics, applied ethics
1. metaethics
focus on universal truths, and where and how ethical principles are developed
2. normative ethics
focus on the moral standards that regulate behaviors
3. applied ethics
focus on specific difficult issues such as euthanasia, capital punishment, abortion, and health disparities
triage
allocating care in emergency situations
Box 7-1: "To Be Guardians of the Ethical Treatment of Patients"
describes the importance of the role of nurses and nursing faculty in achieving high standards of integrity to provide ethical care for our vulnerable patients
NLN: on ethics
"not only is doing the right thing simply how we do business, but our actions reveal our commitment to truth telling and how we always see ourselves from the perspective of others in a larger community."
"values"
attitudes, ideals, or beliefs that an individual or a group holds and uses to guide behavior.
usually expressed in terms of right or wrong
"morals"
provide standards of behavior that guide the actions of an individual or social group, and are established rules of conduct to be used in situations where a decision about right and wrong must be made.
ex: "one should not lie"
"ethics"
a term used to reflect what actions an individual should take and may be "codified," as in the ethical code of a profession.
(Greek: "ethos" means habits or customs")
ex: "one should not life"; clarify definitions of lying and explain whether there are circumstances under which lying might be acceptable.
"bioethics"
the application of ethical theories and principles to moral issues or problems in health care.
bioethics is concerned with determining what should done in a specific situation by applying ethical principles.
ex: discussions about genetic testing often have a strong bioethical component surrounding use of knowledge from this type of testing.
medical advances sometimes create ethical dilemmas for health care providers:
ex: a patient may be "kept alive" even when there is no discernible brain activity or hope for the return of spontaneous respiration. The situations sometimes raise serious questions for nurses about the meaning of life and what constitute being "alive"
ANA position statement on ethics
(1994): "The Code [of Ethics] for Nurses is non-negotiable and that each nurse has an obligation to uphold and adhere to the code of ethics."
*the Code establishes a clear standard by which nurses make ethical decisions and carry out their duties.
nurses must think critically about their own personal values and morals
ex: if a nurse's personal moral belief is that abortion is wrong under any circumstances, he or she would find untenable the requirements of a work setting in which pregnancy terminations are performed for genetic disorders.
*by understanding their personal values, nurses can anticipate situations in which their personal morals and professional ethics may be in conflict.
moral reflection
critical analysis of one's morals, beliefs,a dance tons - is a process through which a person develops and maintains moral integrity
moral integrity
in a professional setting is a goal in which one's professional beliefs and acids are assessed and analyzed so that professional ethics continue to mature and respond to changes in practice.
"moral distress"
typically described as a response to a situation when nurses are faced with ethical dilemmas but also encounter institutional constraints that limit their actions
*the pain or anguish affecting the mind, body, or relationships in response to a situation in which the person is aware of a moral problem, acknowledges moral responsibility, and makes a moral judgment about the correct action.
Johnstone and Hutchinson (2015):
noted, "Linchpin to the theory of moral distress is the idea that nurses know what is the right thing to do but are unable to cary it out."
NICU
neonatal intensive care unit
grade IV intraventricular hemorrhage
severe bleeding into the ventricles of the brain
"full code"
meaning that all efforts will be made to resuscitate her in case her heart stops
this nurse experienced moral distress,
a sense of being unable to act in a way that he believes is moral in this situation (taking the premature infant off life support)
Professional ethical codes such as that of the ANA provide substantial guidance in determining
how to respond and act in practice settings when faced with an ethical dilemma.
Kohlberg (1976, 1986) proposed three levels of moral reasoning as a function of cognitive development:
Pre-conventional level
Conventional level
Post-conventional level
Pre-conventional level
The individual is inattentive to the norms of society when responding to moral problems.
The individual's perspective is self-centered.
In stage 1, the person responds to punishment.
In stage 2, the person responds to the prospect of personal reward.
Pre-conventional level of moral development was observed in children younger than 9 years of age, some adolescents, and adult criminal offenders.
Conventional level
characterized by moral decisions that conform to the expectations of one's family, group, or society.
In stage 3, the person makes moral choices based on what is pleasing to others.
In stage 4, the person makes moral choices based on a larger notion of what
is desired by society (including family or cultural group norms)
This level was observed among most adolescents and adults. "Because it's the law"
Post-conventional level
involves more independent modes of thinking than previous stages. The individual has developed the ability to define his or her own moral values.
They may ignore both self-interest and group norms in making moral choices.
For example, they may sacrifice themselves on behalf of the group. Part of their moral reasoning and behavior is based on a socially agreed-on standard of human rights (Haynes, Boese, and Butcher, 2004). People create their own morality, which may differ from society's norms. Only a minority of adults achieves this level.
Progression through Kohlberg's levels and their corresponding stages occurs
over varying lengths of time for different individuals. The stages are sequential, they build on each other.
An environment that offers people opportunities for group participation, shared decision-making processes, and responsibility for the consequences of their actions also promotes
higher levels of moral reasoning.
Gilligan (1982) was concerned that Kohlberg did not adequately recognize
women's experiences in the development of moral reasoning. (Kohlberg's inattention to gene differences meant that his theory was inadequate in explaining women's moral development)
"The moral person is one who responds to needs and demonstrates a consideration of care and responsibility in relationships."
Gilligan's stages of moral reasoning
Each transition resulted in a critical reevaluation of the conflict between selfishness and responsibility.
*described a moral development perspective focused on care.
1. orientation to individual survival
2. focus on goodness with recognition of self-sacrifice
3. the morality of caring and being responsible for others, as well as self.
Gilligan suggested that women view moral dilemmas in terms of conflicting responsibilities
women often exhibited a focus on ___, whereas men more often exhibited a focus on ___
care; justice
____ at times combine the care/justice perspective when forced to make ethical decisions.
Nurses;
Nurses have SHIFTED from the moral perspective of care to a JUSTICE orientation where universal rules and principles are used in moral decision making
the ethical implications of day-to-day practice and decisions are often obscured by ____
more dramatic scenarios.
ex: Nurse Michelle: time management p. 131
theories of ethics
like all theories, are conceptual descriptions of phenomena. In ethics, the phenomena are understandings of behaviors in terms of their moral implications.
deontology
Greek "deon," which means obligation or duty.
- an act was moral if its motives or intentions were good, regardless of the outcome.
Ethical action consists of doing one's duty or honoring one's obligations to human beings:
to do one's duty was right; to not do one's duty was wrong.
Act deontologists
determine the right thing to do by gathering all the facts and then making a decision
Rule deontologists
emphasize that principles guide our actions
ex: "always keep a promise" "never tell a lie"
Deontologists are not concerned with the consequences of adhering to certain rules of actions. If one's guiding principle is "always keep a promise", a deontologist will keep promises, even if circumstances have changed.
Utilitarianism
moral rightness of an action is determined solely by its consequence
first described by David Hume and was developed further by other philosophers (David Hume (1711-1776), Jeremy Bentham (1748-1832), and John Stuart Mill (1806-1873)
assumes that it is possible to balance good and evil with a goal that most people experience good rather than evil.
ex: triage
those who subscribe to Utilitarian ethics believe that
"What makes an action right or wrong is its utility, with useful actions bringing about the greatest good for the greatest number of people"
in other words, maximizing the greatest good for the benefit, happiness, or pleasure of the greatest number of people is moral.
Triage
the sick or injured are classified by the severity of their condition to detainee priority of treatment.
ex: plane crash in a remote area; only those with the possibility of surviving can be transported. Those with less serious burns can be managed at a smaller hospital. This means that someone has to decide who will and who won't be treated. The most gravely injured will not be treated until those with a reasonable change of survival are taken care of, although this means that some of the more severely injured will die awaiting care.
As a function of Utilitarianism, Triage is accepted as an ethical basis for determining treatment.
Utilitarianism : basis for deciding how health care dollars are spent
ex: money is more likely to be spent on research for diseases that affect large numbers of people than on research for diseases that affect few.
Virtue ethics
emphasizes the character of the decision-maker.
Arisotle: Virtues are tendencies to act, feel, and judge that develop through appropriate training but come from natural tendencies. (actions are built from a degree os inborn moral virtue)
Virtues refer to specific character traits including
truth telling, honesty, courage, kindness, respectfulness, compassion, fairness, and integrity among others.
these become obvious though actions
When virtuous people are faced with ethical dilemmas, they will instinctively choose to do the right things because they have developed character through life experiences
Virtues may be what separate the competent nurse from the __
exemplary nurse.
practicing in an ethical manner requires a decision to act within the ethical code of the profession, demanding commitment, personal investment, and the intention and motivation to become a good nurse.
Principalism -
uses key ethical principles of beneficence (do good), nonmaleficence (do no harm), autonomy (respect for the perinea's ability to act in her own best interests), and justice in resolution of ethical conflicts or dilemmas
fidelity (faithfulness) and veracity (truth telling) are also important ethical principles that may be at work in managing ethical dilemmas.
Code of Ethics for Nurses regarding respect
"The nurse practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems"
6 ethical principles
autonomy, beneficence, nonmaleficence, justice, fidelity, and veracity
autonomy
The principle of autonomy asserts that individuals have the right to determine their own actions and the freedom to make their own decisions.
Autonomous decisions are based on:
Individuals' values
Adequate information
Freedom from coercion
Reason and deliberation
Autonomy poses a problem for health care workers when
the patient is incompetent to make decisions because of physical conditions, psychological or mental status, or developmental age
ex: infants or small children.
Beneficence
Beneficence is commonly defined as "the doing of good."
A beneficent act may conflict with other ethical principles, most often autonomy:
Even though a nurse or physician may understand that a particular treatment has a benefit for the patient, the patient may decide to forego that treatment (autonomy) for a variety of reasons.
ex: an elderly patient is at a high risk of falls and it is suggested that she have a sitter to stay with her at night. She objects because she is dignified and proud, but what is good for her is to have a sitter, even though it is in conflict with what she wants.
Nonmaleficence
is defined as the duty to do no harm.
Code of Ethics for Nurses (ANA, 2015): The nurse must not act in a manner that would intentionally harm the patient:
Double effect
Ex: chemotherapy and bone marrow transplantation procedures. They both can make patients sicker for a time and pose risk, but there is a possibility of cure or remission at the expense of the temporary harm.
"double effect"
considers the intended foreseen effects of actions by the professional nurse.
It is ethically permissible, however, to do what may produce a distressful or undesirable result if the intent is to produce an overall good effect.
Four Conditions must be present to justify the use of the double effect principle:
1. The action must be good or at least morally indifferent (neutral).
2. The health care provider must intend only the good effects.
3. The undesired effects cannot be a means to the end or good effect.
4. There is a favorable balance between desirable and undesirable effects.
Justice
equals should be treated the same and that unequals should be treated differently. (those with the same diagnosis and health care should receive the same care, and those with greater or lesser needs should receive care that is appropriate to their needs)
ex: basic to the principle of justice: questions of WHO received healthcare and whether health care is a right or a privilege.
Health disparities among ethnic minorities with regard to the types of treatments and services that are available represent a difficult problem in terms of justice. "racial disparity exists in health care access, treatment options, and outcomes"
How does one decide what is just when a natural disaster strikes, crippling health care facilities, and providers are left with critically ill patients in dire circumstances?
Sherri Fink, "Five Days at Memorial", an investigation of the patients' deaths after Katrina
thinking about situations in disasters in advance is a way to prepare for the troublesome ethical situations that arise under conditions that are barely imaginable under normal circumstances.
Fidelity
faithfulness or honoring one's commitments or promises.
In every situation, the harmful consequences of the promised action must be weighed against the benefits of promise keeping
Ex: fidelity is a key foundation for the nurse-patient relationship. When nurses receive patient assignments and accept hand-off reports on those patients, they are committed to providing care to those assigned to them. Failure to carry out the prescribed care is unethical and may constitute patient abandonment or neglect.
Veracity
is defined as telling the truth, or not lying.
Hines (2008): True cultural humility is tied to respecting
patient preferences for information and for treatment.
-Cultural humility - a posture that requires that clinicians make every effort to understand their patients' beliefs and how their patients want themselves and their illness to be treated
"paternalism"
Ex: In nursing, telling the truth is expected. In some rare instances, nurses are constrained in some health care systems that place limits on what a nurse can tell a patient. A nurse can still remain truthful by telling the patient "the doctor prefers to discuss her findings with her patients directly".
paternalism
someone believes that he or she knows what is best for another person who is competent to make his or her own autonomous judgments about a course of action.
ex: withholding information from a patient.
Cultural humility -
a posture that requires that clinicians make every effort to understand their patients' beliefs and how their patients want themselves and their illness to be treated
A code of ethics
is a social contract through which the profession informs society of the principles and rules by which it functions.
Shapes professional self-regulation
Serves as guidelines to the members of the profession
Ethical practice has been a priority for nurses in America since the late 19th century. in 1893, the Nightingale Pledge
became the first public evidence of an ethical code in nursing.
ANA Code of Ethics for Nurses with Interpretative Statements (latest: 2015)
is the nursing profession's expression of its ethical values and duties to the public.
Nursing: Scope and Standards of Practice
is another very important document for nurses; it defines standards of practice and standards of professional performance.
"the RN practices ethically"
ICN code of ethics
International Council of Nurses
also has published a code of ethics for the profession.
this document discusses the rights and responsibilities of nurses related to people, practice, society, co-workers, and the profession
nurses encounter situations daily that require them to make professional judgments and act on those judgments
Ethical decision making requires that the nurse make judgments or devisions when 2 or more of their values are incongruent
The best decision will be made: in an ethical dilemma, there is usually not a clear-cut right or wrong answer. Instead, we search for the best answer.
Steps in Ethical Decision-Making
Clarify the ethical dilemma
Gather additional data
Identify options
Make a decision
Act
Evaluate
1. Clarify the ethical dilemma:
what is the specific issue in question? Who should actually make the decision? Who is affected by the dilemma? Determine the ethical principle or theory related to the dilemma. Are there value conflicts? What is the time frame for the decision?
2. Gather additional data:
after the dilemma is clarified, more information still needs to be collected. Clarity is enhanced when you have as many facts as possible about the situation. Make sure you are up to date on any legal cases or precedents related to the situation, because ethical and legal issues often overlap.
3. Identify options:
the more options that are identified, the more likely it is that an acceptable solution can be identified. Brainstorm with others, and consider every possible alternative that you can come up with.
4. Make a decision:
think through the options that are identified and determine the impact of each option. Ethical principles and theories, as well as basic human values, may help determine the significance of each option. When a nurse is confronted with an ethical dilemma, an active decision should be made as opposed to refusing to make a decision (Which is irresponsible professional behavior)
5. Act:
once a course of action is determined, the act must be carried out. This usually involves working with others.
6. Evaluate:
unexpected outcomes are common, so decision makers should consider the effect an immediate decision may have on future ones.
reflecting on a decision and action can help determine whether a different course of action might have resulted in a better outcome. If the action accomplished its purpose, the ethical dilemma should be resolved. If not, engage in additional deliberation and reexamine alternative options.
Ethical dilemmas can arise through:
1. personal value systems
2. peers' and other professionals' behaviors
3. patients' rights
4. institutional and societal issues
5. patient data access issues
1. personal value systems
Values
are learned beliefs that help people choose among difficult alternatives, even when there may not be a good choice.
influence the behavior of individuals
Value systems enable people to resolve conflicts and decide
on a course of action based on a priority of importance.
Professions have a "built-in" value system known as
a code of ethics
A difficult issue for turing students to come to terms with on occasion is when their personal values are in conflict with their professional values (when they are faced with a professional situation that has some elements not in keeping with the nurse's personal moral code or values.
**Professional ethics OUTWEIGH personal ethics in a professional setting.
it is incumbent on the nurse to find a work situation in which her personal ethics are not routinely challenged by situations that occur with patients.
MFPR
Multifetal pregnancy reduction
a form of pregnancy termination in which a multiple pregnancy is reduced to one or two remaining embryos
2. peers' and other professionals' behaviors
All practicing nurses participate as members of the health care team.
Involves cooperation and collaboration with other professionals.
Conflicts especially occur in stressful situations.
conflicts relevant to human rights often center around one of the ethical principles discussed earlier:
autonomy, beneficence, nonmaleficence, veracity, or justice
A disturbing reality:
the presence of providers who fail to meet standards of care routinely, who may simply be incompetent, or who participate in actions that are considered unethical by other professionals.
unethical cations result when health care workers break basic norms of conduct toward others, especially the patient.
Nurses face 2 serious ethical challenges in today's sociocultural context:
1. the use of social media
2. substance use/abuse
The widespread use of social media, such as Facebook, twitter, and blogs, has created 2 distinct problems:
1. the transmission of potentially identifiable patient information
2. the blurring of professional and personal boundaries.
ANA developed
a Social Networking Toolkit
to help nurses understand their responsibilities when using social media.
NCSBN published a white paper,
A Nurse's Guide to the Use of Social Media
it is important to realize that the principles undergirding the protection of patients regarding social media
DO NOT CHANGE, even as digital media continue to grow and thrive.
ex: what's inappropriate for posing on Facebook is also inappropriate for snapchat and instagram.
ethical use of social media
1. you must not post anything about your patients that may violate their rights to privacy and confidentiality
2. never post images of patients
3. online contact with
patients blurs professional and personal boundaries
4. you are ethically obligated to report any breach in confidentiality or privacy that you encounter online.
5. remember that posting anything leaves a digital footprint forever
Nurses and other health care professionals impaired by drug dependence, alcohol abuse, or other addictions
when a colleague appears to be under the influence of some type of substance, the decision to report is usually easy, even if personally painful.
be aware, however, that certain acts medical conditions can change behavior or gait; they could be experiencing a medical emergency
when a colleague is showing a pattern of behavior that may indicate a substance abuse problem:
the dilemma can be overwhelming
slurred speech, unsteady gait, combativeness, and smell of alcohol on breath
the process must begin with a co-worker who follows the ANA ethical standard that obligated professional nurses to
report colleagues who "pose a threat or danger to patients, self, or others"
3. patients' rights
2003: American Hospital Association and "The Patient Care Partnership"
still currently used; the document describes what patients can and should expect while hospitalized including a safe, clean environment; quality care; involvement in one's own care that includes a discussion regarding the treatment plan; help with understanding the bill and filing insurance claims; and preparation to leave the hospital
PSDA
Patient Self-Determination Act 1990
enacted in dec 1991: the PSDA is a safeguard for patients' rights, giving patients the legal right to determine how vigorously they wish to be treated in life or death situations, and calls for hospitals to abide by patients' advance directives.
It specifies that any organization receiving Medicare or Medicaid funds must inform patients of state laws regarding directives, document the existence of directives in the patient's medical record, educate staff regarding directives, and educate the community about directives.
advance directives
are legal documents that indicate the wishes of individuals in regard to end-of-life issues.
designed to ensure individuals the rights of autonomy, refusal of medical intervention, and death with dignity.
Families should talk about how each member wants critical situations to be handles.
Individual preferences can then be understood.
the ideal time for patients to make difficult end-of-life decisions is
well in advance of the need (beforehand)
assignment of health care power of attorney
health care power of attorney
a trusted person may be appointed to make decisions on behalf of the patient when they cannot make them on his or her own.
2 distinct ethical issues that affect nursing (in regards to immigration and migration)
1. communication/language problems between patients and health care providers
2. migration of nurses
Communication/language problems between patients and health care providers
Nurses who are not bilingual or fluent in medical terminology should defer to a professional medical interpreter for explanations of procedures, diagnoses, obtaining informed consent, and other complex health care related issues
Interpretation
spoken word
Translation
written word
medical interpretation
requires extensive knowledge of medical terminology, in addition to cultural humility and sensitivity to the needs of the patient
2nd issue: international nurse migration
the influx of nurses from other countries coming to the US seeking better pay and working conditions
poses problems: exacerbates nuring shortages in other countries and documentation of competency to provide safe nursing care (NCLEX-RN)
ANA's position on international nurse migration
opposition of the use of immigration to solve the nursing workforce shortage:
1. congress had failed to provide adequate funding for domestic schools of nursing
2. the health care industry had failed to establish a workplace environment conducive to the retention of experienced US nurses in patient care
3. the US had failed to engage in active workforce planning to
sustain nursing's and other health care professions' workforces into the future.
an open-immigration policy has the potential to
"undermine our multibillion-dollar effort to combat AIDS and malaria by potentially worsening the shortage of health workers in poor countries. We're pouring water in a bucket with a hole in it, and we drilled the hole.
2nd ethical issue is the documentation of competency to provide safe nursing care
which occurs in the passing of the NCLEX by graduates of approved american nursing schools.
nurses who speak english as a 2nd language also pose a barrier with communication difficulties.
cultural acclimation to the US may pose particular challenges as well.
4. institutional and societal issues
Ethical dilemmas between nurses and the organizations that employ them may develop over policies dictated by the organizations or mandated by governmental agencies.
Centers for Medicare & Medicaid Services (CMS)
health care organizations are subject to public scrutiny and accountability and those who receive funds from CMS are under even more scrutiny.
ethics committees
created to assist with ethical dilemmas in institutional settings.
these are multidisciplinary groups charged with the responsibility of providing consultation and emotional support in situations in which difficult ethical choices are necessary.
those desiring help, usually clinical care givers, refer cases to the committee for additional direction.
5. patient data access issues
EHRs are powerful sources for the storage and transmission of information about patients across health care specialties and disciplines.
those in positions to access health care info share a great responsibility to protect this information from unauthorized use.
computer ethics
have been in existence since the 70s, but in recent years there has been renewed interest in scholarly inquiry in nursing informatics as the use of technology has become standard in health care institutions.
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