Application of Ethics in the Community
advocacy, p. 135
assessment, p. 133
assurance, p. 133
beneficence, p. 129
bioethics, p. 126
code of ethics, p. 127
communitarianism, p. 131
consequentialism, p. 129
deontology, p. 129
distributive justice, p. 129
ethical decision making, p. 127
ethical dilemmas, p. 127
ethical issues, p. 127
ethics, p. 129
feminine ethic, p. 132
feminist ethics, p. 132
feminists, p. 132
moral distress, p. 128
morality, p. 132
nonmaleficence, p. 129
policy development, p. 133
principlism, p. 130
respect for autonomy, p. 129
utilitarianism, p. 129
values, p. 129
virtue ethics, p. 131
virtues, p. 131
—See Glossary for definitions
Mary Cipriano Silva, PhD, RN, FAAN
Mary Cipriano Silva is a professor emerita at George Mason University in Fairfax, Virginia. She is a nationally recognized and award-winning ethics scholar who has published extensively in health care ethics for over 35 years.
Jeanne Merkle Sorrell, PhD, RN, FAAN
Jeanne Merkle Sorrell is currently Senior Nurse Researcher at the Cleveland Clinic in Ohio, and professor emerita at George Mason University. Her current research focuses on ethical concerns of persons with Alzheimer’s disease and their families and professional caregivers. She has incorporated her research findings into an award-winning educational video, Quality Lives: Ethics in the Care of Persons with Alzheimer’s, and a play, Six Characters in Search of an Answer, which was selected for the 2007 Sigma Theta Tau International Nursing Media Award.
James J. Fletcher, PhD
James J. Fletcher is a professor emeritus of philosophy in the Department of Philosophy at George Mason University, where he specializes in bioethics. In addition to his research and teaching in bioethics, he is a member of the ethics committee and chair of the Human Research Review Committee of a community hospital. He sits on the Institutional Review Board of a local biotechnological company, serves as a member of Data and Safety Monitoring Boards for the National Institutes of Health, and is a member of a District Disciplinary Committee of the Virginia State Bar.
Nurses who practice in the community focus on protecting, promoting, preserving, and maintaining health while preventing disease. These goals reflect the ethical principles of promoting good and preventing harm. In addition, nurses struggle with the rights of individuals and families versus the rights of local groups within a community. On the other hand, nurses struggle with the rights of a community or population versus the rights of individuals, families, and local groups within a community. These two types of struggle reflect the tensions between respect for autonomy, rights-based ethical theory, and community-based ethical theory.
Nurses also deal with consequence-based ethical theory, obligation-based ethical theory, and the ethical components of advocacy, justice, health policy, caring, women’s moral experiences, and the moral character of health care practitioners. They are guided by codes of ethics and ethical decision-making frameworks. The purpose of this chapter, then, is to make explicit the preceding content as it relates to the ethics inherent in nursing.
The history of nursing is discussed in detail in Chapter 2. The focus here is a brief history of nursing and public health ethics and the relationship between them and nursing.
Modern nursing has a rich heritage of ethics and morality, beginning with Florence Nightingale (1820–1910). Her values and the moral significance she inculcated into the profession have endured. She saw nursing as a call to service and viewed the moral character of persons entering nursing as important. She also viewed nursing within a broad social context, where poor people mattered and where soldiers harmed in the Crimean War (1854–1856) did not have to endure unhealthy environments. Because of her commitment to poor individuals in communities, as well as her stances on primary prevention and population-based evidence that healthy environments save soldiers’ lives, she is seen as nursing’s first enduring moral leader who defined the community as her client.
In 1860, Nightingale established the first nursing program in London. It was hospital based, but the curriculum contained not only care of the sick, but also public health concepts with their inherent ethical tenets. Many of these programs were associated with religious institutions. Students, therefore, often received ethics courses with a slant toward a particular religion’s values. Soon thereafter in the United States, the notion of hospital-based nursing programs took hold, but nursing practice in the community was not a part of the curricula.
In the 1960s, two seminal events occurred. First, the American Nurses Association (ANA) recommended that all nursing education should occur in institutions of higher education. As this process slowly took place, ethics, as a course per se, was removed from many schools of nursing, although ethical values remained. Second, because of major advances in science and technology that affected health care, the field of bioethics began to emerge and was reflected in nursing curricula. Today, the vast majority of nursing programs integrate bioethical content into their courses or have separate courses on this topic; some do both. Although some of these courses relate bioethics to community nursing, the emphasis has been primarily on acute care nursing.
Nurses’ codes of ethics are important in the history of public health nursing practice. The Nightingale Pledge is generally considered to be nursing’s first code of ethics (ANA, 2001). After the Nightingale Pledge, a “suggested” code and a “tentative” code were published in the American Journal of Nursing but were not formally adopted. In 1950, however, the Code for Professional Nurses was formally adopted by the ANA House of Delegates. In 1956, 1960, 1968, 1976, and 1985, the code was amended or revised. In 2001, after 5 years of work, the Code of Ethics for Nurses with Interpretive Statements was adopted by the ANA House of Delegates (ANA, 2001).
Nurses should also be familiar with the first known international code of ethics, developed by the International Council of Nurses (ICN) in 1953 (ICN, 1953). Like the ANA code, the ICN code has undergone various revisions and adoptions. The most recent version of the ICN Code of Ethics for Nurses was adopted in 2006 (ICN, 2006).
In addition to codes of ethics, the nursing literature and nursing associations have consistently reflected a commitment to ethics, as well as an awareness of nursing’s ethical obligations to society. From the 1980s to the present, the number of centers for nursing and health care ethics has increased steadily. The majority of these centers are located in academic settings; however, in 1991 the ANA founded its Center for Ethics and Human Rights. The historical contributions have affected the persistent ethicality of nursing. In 2008, the ANA published Nursing and Health Care Ethics: A Legacy and a Vision, which creatively assesses historical contributions of nursing scholars in ethics and explores a vision for the future scholarship of nursing ethics (Pinch and Haddad, 2008).
The bioethics movement of the late 1960s influenced not only nursing ethics, but also public health ethics. However, until recently, the relationship between public health and ethics was implicit rather than explicit (Callahan and Jennings, 2002; Petrini, 2010).
Finally, in 2000, public health professionals, individually and through their associations, initiated the writing of a code of ethics that was supported by the American Public Health Association (APHA). In 2001 the Public Health Code of Ethics was widely disseminated via the APHA website for critique (www.apha.org) and was adopted in 2002 (Olick, 2005). The code presents principles, rules, and ideals to guide public health practice but is not intended to provide a specific action plan for ethical decision making.
Before discussing ethics related to nursing practice in the community, some key ethical terms are defined in Box 6-1. Other ethical terms are defined within the context of the chapter.
Ethical Decision Making
Ethical decision making is that component of ethics that focuses on the process of how ethical decisions are made. The process is the thinking that occurs when health care professionals must make decisions about ethical issues and ethical dilemmas. Ethical issues are moral challenges facing us or our profession. In nursing, one such challenge is how to prepare an adequate and competent workforce for the future. In contrast, ethical dilemmas are human dilemmas and puzzling moral problems in which a person, group, or community can envision morally justified reasons for both taking and not taking a certain course of action. One example of an ethical dilemma is how to allocate resources to two equally needy populations when the resources are sufficient to serve only one of the populations. Ethical theories, principles and decision-making frameworks help us think through these issues and dilemmas.
Ethical decision-making frameworks use problem-solving processes. They provide guides for making sound ethical decisions that can be morally justified. Many such frameworks exist in the health care literature, and some are presented in this chapter. A caveat, however, is in order. Weston (2006, p 22) notes that the first requirement of ethics is to think appreciatively and carefully about moral matters. We should not simply obey rules or authorities without thinking for ourselves; thinking for ourselves is both a moral responsibility and a hard-won right.
The steps of a generic ethics framework are often non-linear, and, with the exception of step 5, they do not change substantially. The rationale for each of the seven steps is presented in Table 6-1. The six approaches to actions or options in the ethical decision-making framework (step 5) are outlined throughout the chapter in the “How To” boxes.
|1. Identify the ethical issues and dilemmas.
|Persons cannot make sound ethical decisions if they cannot identify ethical issues and dilemmas.
|2. Place them within a meaningful context.
|The historical, legal, sociological, cultural, psychological, economic, political, communal, environmental, and demographic contexts affect the way ethical issues and dilemmas are formulated and justified.
|3. Obtain all relevant facts.
|Facts affect the way ethical issues and dilemmas are formulated and justified.
|4. Reformulate ethical issues and dilemmas if needed.
|The initial ethical issues and dilemmas may need to be modified or changed on the basis of context and facts.
|5. Consider appropriate approaches to actions or options.
|The nature of the ethical issues and dilemmas determines the specific ethical approaches used.
|6. Make decisions and take action.
|Professional persons cannot avoid choice and action in applied ethics.
|7. Evaluate decisions and action.
|Evaluation determines whether or not the ethical decision-making framework used resulted in morally justified actions related to the ethical issues and dilemmas.
Two factors affect this ethical decision-making framework: (1) the growing multiculturalism of the American society, and (2) moral distress. First, nurses often deal with ethical issues and dilemmas related to the diverse and at times conflicting values that result from ethnicity. From a moral perspective, what should the nurse do when facing ethnicity conflicts?
Callahan (2000) offers useful insights into these conflicts. He describes four situations in which ethnic diversity can be judged in relationship to cultural standards:
Callahan (2000, p 43) discusses how to judge diversity in the four situations. Regarding situation 1, he states that “we in America imposed some standards on ourselves for important moral reasons; and there is no good reason to exempt [ethnic] subgroups from those standards.” Regarding situations 2 and 3, he suggests a thoughtful tolerance but also some degree of moral persuasion (not coercion) for ethnic groups to alter values so that they are more in keeping with what is normative in the American culture. However, Callahan notes that “in the absence of grievous harm, there is no clear moral mandate to interfere with those values” (p 43). Finally, regarding situation 4, he believes in moral tolerance of non-threatening ethnic traditions, since there is no moral mandate to do otherwise.
Second, since decision making is so central to the practice of nursing, and many decisions are not easy ones to make, spending more time on the experience of ethical or moral distress is useful. Moral or ethical distress occurs when a person is unable to act in a way that he or she thinks is right. You do not feel that you are able to act in a manner consistent with your own values, cultural expectations, and religious beliefs. When this conflict occurs, it can lead to a personal sense of failure in the kind of care you give and to subsequent performance issues and may lead to work and/or career dissatisfaction. However, there are ways to handle moral distress:
It is often useful to talk with colleagues. You may learn that they have similar concerns or that they have found ways to interrupt the stressful situation(s) (Carlock and Spader, 2007). Understanding both multiculturalism and moral distress enhances ethical decision making.
Definition, Theories, Principles
Ethics is concerned with a body of knowledge that addresses such questions as the following: How should I behave? What actions should I perform? What kind of person should I be? What are my obligations to myself and to fellow humans? There are general obligations that humans have as members of society. Among these general obligations are not to harm others, to respect others, to tell the truth, and to keep promises. Sometimes, however, a situation dictates that individuals tell a lie or break a promise because the consequences of telling the truth or keeping the promise may bring about more harm than good. For example, as a nurse you have promised a family that you will visit them at a certain time, but your schedule has gone awry because of unexpected circumstances. One of the other families you visit is in a state of crisis—their adolescent child is suicidal—and your nursing intervention is needed. Most nurses would agree that this is not a good time to keep the original promise. You are morally justified in breaking your promise because you fear that more harm than good would be done if it were kept.
This example illustrates several things about ethical thinking. First, ethical judgments are concerned with values. The goal of an ethical judgment is to choose that action or state of affairs that is good or right in the circumstances. Second, ethical judgments generally do not have the certainty of scientific judgments. For example, nurses diagnose a situation on the basis of the best available information and then choose the course of action that seems to provide the best ethical resolution to the issue. In some situations, the decision is based on outcomes or consequences. That approach to ethical decision making is called consequentialism. It maintains that the right action is the one that produces the greatest amount of good or the least amount of harm in a given situation. Utilitarianism is a well-known consequentialist theory that appeals exclusively to outcomes or consequences in determining which choice to make.
In other situations, nurses touch upon options open to fundamental beliefs. In such circumstances, these nurses may conclude that the action is right or wrong in itself, regardless of the amount of good that might come from it. This is the position known as deontology. It is based on the premise that persons should always be treated as ends in themselves and never as mere means to the ends of others.
Members of the health professions have specific obligations that exist because of the practices and goals of the profession. These health care obligations have been interpreted in terms of a set of principles in bioethics. The primary principles are respect for autonomy, nonmaleficence, beneficence, and distributive justice, as shown in Box 6-2. These principles have dominated the development of the field of bioethics since its inception in the 1960s (Walker, 2009). This approach has been called principlism, and one of its best descriptions and fullest articulations is in the sixth edition of Principles of Biomedical Ethics by Beauchamp and Childress (2008). This approach to ethical decision making in health care arose in response to life-and-death decision making in acute care settings, where the question to be resolved tended to concern a single localized issue such as the withdrawing or withholding of treatment (Holstein, 2001). In these circumstances, preserving and respecting a client’s autonomy became the dominant issue.
Despite its success as a basis for analysis in bioethics, principlism has come under attack (e.g., Callahan, 2000, 2003; Walker, 2009), and there are grounds for the criticism. First, the principles are said to be too abstract and narrow to serve as guides for action. Second, the principles themselves can conflict in a given situation, and there is no independent basis for resolving the conflict. Third, some persons claim that effective ethical problem solving must be rooted in concrete, individual experiences. Fourth, ethical judgments are alleged to depend more on the judgment of sensitive persons than on the application of abstract principles.
The dominance of the principle of respect for autonomy has been challenged by critics concerned about decision making in non–acute care settings, where the ethical decision is more likely to be about, for example, long-term care or access to health care for persons of diverse cultures (Callahan and Jennings, 2002; Walker, 2009). Thus, whereas autonomy may be stressed in acute care settings, an overemphasis on autonomy may inhibit ethical decisions in public health. In public health, beneficence and distributive justice are frequently a greater issue than autonomy. For this reason, it is useful to look at other models for ethical decision making, including models that expand the focus of nursing beyond the individual nurse-client relationship to the social environment and systems that impact health care (Bekemeier and Butterfield, 2005).
Utilitarianism and deontology were developed from the Enlightenment period’s focus on universals, rationality, and isolated individuals. Each theory maintains that there is a universal first principle—the principle of utility for utilitarianism and the categorical imperative for deontology—that serves as a rational norm for our behavior and allows us to calculate the rightness or wrongness of each individual action. Both utilitarianism and deontology also follow the lead of classic liberalism in asserting that the individual is the special center of moral concern (Steinbock, Arras, and London, 2008). Giving priority to individual rights and needs means that these should not be sacrificed for the interests of society (Steinbock, Arras, and London, 2008). The focus on individual rights leads to complications in the interpretation of distributive or social justice.
Distributive or social justice refers to the allocation of benefits and burdens to members of society. Benefits refer to basic needs, including material and social goods, liberties, rights, and entitlements. Wealth, education, and public services are benefits. Burdens include such things as taxes, military service, and the location of incinerators and power plants. Justice requires that the distribution of benefits and burdens in a society be fair or equal. There is wide agreement that the distribution should be based on what one needs and deserves, but there is considerable disagreement as to what these terms mean. Three primary theories of distributive justice are defended today. They are the egalitarian, libertarian, and liberal democratic theories.
Egalitarianism is the view that everyone is entitled to equal rights and equal treatment in society. Ideally, each individual has an equal share of the goods of society, and it is the role of government to ensure that this happens. The government has the authority to redistribute wealth if necessary to ensure equal treatment. Thus, egalitarians are supportive of welfare rights—that is, the right to receive certain social goods necessary to satisfy basic needs, including adequate food, housing, education, and police and fire protection. The weaknesses of egalitarianism are both practical and theoretical. It would be practically impossible to ensure the equal distribution of goods and services in any moderately complex society. Assuming that such a distribution could be accomplished, it would require a coercive authority to maintain it (Coursin, 2009; Hellsten, 1998). Further, egalitarianism is unable to provide any incentive for each of us to do our best, since there is no promise of our merit being rewarded.
The libertarian view of justice holds that the right to private property is the most important right. Libertarians recognize only liberty rights—the right to be left alone to accomplish our goals. Hellsten (1998) notes, “The central feature of the libertarian view on distributive justice is that it is totally individualist. It rejects any idea that societies, states, or collectives of any form can be the bearers of rights or can owe duties” (p 822). Libertarians see a very limited role for government, namely, the protection of property rights of individual citizens through providing police and fire protection. While they also concede the need for jointly shared, publicly owned facilities such as roads, they reject the idea of welfare rights and view taxes to support the needs of others as coercive taking of their property. Given the libertarian rejection of the priority of the state, however, it is not clear where the right to property originates (Hellsten, 1998).
The liberal democratic theory is well represented by the work of John Rawls (2001). Rawls attempts to develop a theory that values both liberty and equality. He acknowledges that inequities are inevitable in society, but he tries to justify them by establishing a system in which everyone benefits, especially the least advantaged. This is an attempt to address the inequalities that result from birth, natural endowments, and historic circumstances. Imagining what he calls a “veil of ignorance” to keep us unaware of our actual advantages and disadvantages, Rawls would have us choose the basic principles of justice (p 15). Once impartiality is guaranteed, Rawls (2001, p 42) maintains that all rational people will choose a system of justice containing the following two basic principles:
Each person has the same indefeasible claim to a fully adequate scheme of equal basic liberties, which scheme is compatible with the same scheme of liberties for all; and social and economic inequalities are to satisfy two conditions: first, they are to be attached to offices and positions open to all under conditions of fair equality of opportunity; and second, they are to be to the greatest benefit of the least advantaged members of society (the difference principle).