The civil rights that protect conscientious health care providers against discrimination, allowing them the right to act according to the dictates of their conscience.

Utilitarianism

An ethical theory stating that the best decision is one that brings about the greatest good for the most people.

Values

Ideas of life, customs, and ways of behaving that society regards as desirable.

Veracity

An ethical duty to tell the truth.

Ethical dilemmas are the puzzles of life.

Additional resources are available online at:

http://evolve.elsevier.com/Cherry/

VIGNETTE

Joe Smith has accepted a position as the nurse manager in a very busy urban emergency department serving patients from diverse cultures. Among Joe’s many responsibilities is developing the 24-hour, 7-day–week work schedules of the department’s nursing workforce in which he has 10 unfilled positions. Another responsibility is implementing the hospital’s policy of offering all patients, regardless of cultural beliefs, the right to an advance directive for end-of-life care. At the same time, Joe must ensure that each patient who enters the emergency department receives appropriate high-quality care from competent professional care providers who respect and respond to patients’ individual needs and desires. With these responsibilities come challenges, sometimes so significant that the nurse manager is faced with an ethical dilemma.

Questions to Consider While Reading This Chapter

1. How will ethical and bioethical issues in nursing and health care affect my professional nursing practice?

2. What ethical theories and principles serve as a basis for nursing practice?

3. How am I to think about ethical dilemmas with moral integrity and consistency with my belief system?

4. What goals can I establish to move me toward excellence in moral and ethical reasoning?

5. How can I assist patients and families who face difficult ethical decisions?

Chapter Overview

In a nursing education program, nursing students only begin to embrace the complex and dynamic profession of nursing. Prelicensure nursing education is only an introduction to a discipline in which there are no knowledge boundaries. The abundance of nursing practice information is evident from a quick glance across the nursing textbook selections in the campus or online bookstore.

Most of that information addresses the “how-to” aspects of nursing care. The scientific aspects of nursing care are evolving more rapidly than ever as a host of nurse researchers delve into questions about the safe, competent, and therapeutic aspects of professional nursing care. As quickly as nursing science produces new nursing knowledge, how-to information is shared through professional journals, textbooks, and electronically through Internet resources. The scientific aspects of care evolve constantly through how-to research.

A myriad of potential questions surpass the how-to body of knowledge that is inherent in the profession of nursing. Everywhere in today’s health care delivery system are potential questions of another nature—the “how should” questions, which are challenging and sometimes evolve into ethical dilemmas. The “how should” questions that the emergency department nurse manager faces may sound something like the following:

• How should I determine the competency of an acutely ill 80-year-old patient who comes to the emergency department without an advance directive? Is her competency intact? How should I determine whether she is capable of giving an informed advance directive?

• How should I act if her decision for her own end-of-life care is not consistent with what her family wants for her? Or how should I respond if the family, because of cultural beliefs, will not even allow information about end-of-life care to be shared with their loved one?

• How should I view the care of this 80-year-old patient? Is an emergency resuscitation effort for an 80-year-old considered ordinary and routine, or is it considered extraordinary and heroic?

• How should I respond to her if, in the course of efforts to stabilize her, she calls me in to ask me whether she is dying?

• How much of the truth is warranted?

• How should I decide when the availability of one-on-one trauma care beds becomes threatened and the decision must be made to move someone out of one bed to make room for this 80-year-old woman whose condition is rapidly deteriorating?

• Is the life of this 80-year-old woman any less significant than that of the 40-year-old father of four who has just been admitted after a tragic car accident?

• How should I feel when this 80-year-old patient is entered into a research study designed to test a new drug for flash pulmonary edema from congestive heart failure that has previously only been tested on a younger population?

• How should I make staffing assignments when the number of nurses on a given shift is insufficient to provide effective and adequate emergency department care to all?

• How should I respond when one of the few nurses reporting to work on a given day refuses to accept the care of patients because of inadequate staffing?

• How should I react when presented with situations that test my own sense of conscience and moral integrity?

This chapter introduces the nursing student to a different aspect of nursing care—the “how should” aspect or, as it is more appropriately called, the ethical aspect. Ethics is a system for deciding, based on principles, what should be done. With the goal of developing excellence in moral and reasoning ability, the nursing student begins a career-long process of ethics acculturation. This process allows the professional nurse to practice with an increasing level of understanding that goes beyond the scientific and moves toward a more complete and whole understanding of human existence.

Nursing Ethics

Nursing ethics is a system of principles concerning the actions of the nurse in his or her relationships with patients, patients’ family members, other health care providers, policymakers, and society as a whole. A profession is characterized by its relationship to society. The results of the 2011 Gallup poll on professional honesty and ethics as reported in a number of news outlets indicate that the public ranks nursing as the most ethical of all professions, and has for more than a decade. Codes of ethics provide implicit standards and values for the professions. A nursing code of ethics was first introduced in the late nineteenth century and has evolved through the years as the profession itself has evolved and as changes in society and health have come about. Current dynamics, such as the emerging genetic interventions associated with therapeutic and reproductive cloning, debates about securing stem cells for research and treatment, evolving legal definitions of family, ongoing questions about euthanasia and assisted suicide, and escalating threats to the effective delivery of health care as a result of significant nursing shortages, now being called ethical climate in the workplace, bring nursing’s code of ethics into the forefront (Boxes 9-1 and 9-2).

BOX 9-1 AMERICAN NURSES ASSOCIATION CODE OF ETHICS FOR NURSES

• The nurse, in all professional relationships, 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.

• The nurse’s primary commitment is to the patient, whether an individual, family, group, or community.

• The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.

• The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care.

• The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.

• The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.

• The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.

• The nurse collaborates with other professionals and the public in promoting community, national, and international efforts to meet health needs.

• The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, maintaining the integrity of the profession and its practice, and shaping social policy.

Reprinted with permission from American Nurses Association: Code of ethics for nurses with interpretive statements, Washington, DC, 2001, American Nurses Publishing, American Nurses Foundation, American Nurses Association. Available online at www.nursingworld.org/about/01action.htm#code.

BOX 9-2 INTERNATIONAL COUNCIL OF NURSES CODE OF ETHICS FOR NURSES

• The fundamental responsibility of the nurse is fourfold: to promote health, to prevent illness, to restore health, and to alleviate suffering.

• The need for nursing is universal. Inherent in nursing is respect for life, dignity, and rights of humans. It is unrestricted by considerations of nationality, race, creed, color, age, sex, politics, or social status.

• Nurses render health services to the individual, the family, and the community and coordinate their services with those of related groups.

Nurses and People

• The nurse’s primary responsibility is to those people who require nursing care.

• The nurse, in providing care, promotes an environment in which the values, customs, and spiritual beliefs of the patient are respected.

• The nurse holds in confidence personal information and uses judgment in sharing this information.

Nurses and Practice

• The nurse carries personal responsibility for nursing practice and for maintaining competence by continual learning. The nurse maintains the highest standards of nursing care possible within the reality of a specific situation.

• The nurse uses judgment in relation to individual competence when accepting and delegating responsibilities.

• The nurse, when acting in a professional capacity, should at all times maintain standards of personal conduct that reflect credit on the profession.

Nurses and Society

• The nurse shares with other citizens the responsibility for initiating and supporting action to meet the health and social needs of the public.

Nurses and Coworkers

• The nurse sustains a cooperative relationship with coworkers in nursing and other fields.

• The nurse takes appropriate action to safeguard the patient when his or her care is endangered by a coworker or any other person.

Nurses and the Profession

• The nurse plays a major role in determining and implementing desirable standards of nursing practice and nursing education.

• The nurse is active in developing a core of professional knowledge.

• The nurse, acting through the professional organization, participates in establishing and maintaining equitable social and economic working conditions in nursing.

From International Council of Nurses: ICN code for nurses: ethical concepts applied to nursing, Geneva, 2005, Imprimiéres Populaires.

Bioethics

Nursing ethics is part of a broader system known as bioethics. Bioethics is an interdisciplinary field within the health care organization that has developed only in the past four decades. Whereas ethics has been discussed since there was written language, bioethics has developed with the age of modern medicine, specifically with the development of hemodialysis and organ transplantation. New questions surface as science and technology produce new ways of knowing. Think of the questions that come from stem cell research, sexual reassignment, and reproductive-assisting technologies such as donor insemination, in vitro fertilization, removal of unused zygotes, surrogate parenting, and the ever-evolving practice of organ transplantation. Bioethical questions have emerged from experiences with natural disasters such as Hurricane Katrina in 2005. Bioethics is a response to these and other contemporary advances and challenges in health care. It is difficult to imagine a time when answers will be more plentiful than bioethical questions.

Dilemmas for Health Professionals

Physicians, nurses, social workers, psychiatrists, epidemiologists, clergy, philosophers, theologians, researchers, and policymakers are joining to address ethical questions, difficult questions, and right-versus-wrong questions. As they seek to deliver quality health care, these professionals debate situations that pose dilemmas. They are confronting situations for which there are no clear right or wrong answers. Because of the diverse society in which health care is practiced, there are at least two sides to almost every issue faced.

Every specialization in health care has its own set of questions. Life and death, the margin of viability, quality of life, design of life, one life offering cure for another, right to decide, informed consent, medical confidentiality, and alternative treatment issues prevail in every field of health care from maternal-child to geriatric care; from acute episodic to intensive, highly specialized care; and from hospital-based to community-based care. Questions about the economics of nursing care and the use of technologies in the diagnosis and treatment of illness abound. In every aspect of the nursing profession lies the more subtle and intricate questions of how this care should be delivered and how should one decide when choices are in conflict.

Many nursing students do not consider health care and the practice of nursing in terms of the personal, truthful, honest, faithful (keeping promises to patients), qualitative, and subjective side; rather they look at it only in terms of the technical, quantitative, and objective side. Yet there most definitely are factors that influence the way patients actually are treated, or at least the way they perceive their treatment, that go beyond the data-driven aspect. In many ways, advanced technology has changed the face of health care and created the troubling questions that have become central in the delivery of care.

Dilemmas Created by Technology

Advances in health care through technology have created new situations for health care professionals and their patients. For the very young and old and for generations in between, illnesses once leading to mortality have become manageable and are classified as high-risk or chronic illness. Although people can now be saved, they are not being saved readily or inexpensively. Care of the acutely or chronically ill person sometimes creates hard questions for which there are no easy or apparent answers. Mortality for most will be a long drawn-out phenomenon, laced with a lifetime of potential conflicts about what ought to be done.

Even the nature of life itself and the technical manipulation of deoxyribonucleic acid (DNA) are under investigation. Health care professionals who adhere to an exclusively scientific or technologic approach to care will be seen as insensitive and will fail to meet the genuine needs of the patient, needs that include assistance with these more subjective concerns, such as how to think about the many advanced care choices laid before them.

Today’s professional nurse will be deemed competent only if he or she can provide the scientific and technologic aspects of care and has the ability to deal effectively with the ethical problems encountered in patient care. A competent nurse is an ethically sensitive nurse (Weaver et al, 2008) who can deal with the human dimensions of care that include a search for what is good and right and for what is accurate and efficient. The previously listed “how should” questions are just as important as the how-to questions surrounding day-to-day decision making in the emergency department or the care of the 80-year-old patient introduced previously. As the nurse seeks to understand the how-to aspects of nurse management and patient care, such as how to best staff a busy emergency department at a time of nursing shortage and how to provide comfort measures for dyspnea and pharmacologic care against the threat of organ dysfunction, he or she also must seek to understand more.

Answering Difficult Questions

Care that combines human dimensions with scientific and technical dimensions forces some basic questions:

• What is safe care?

• What effect might a patient’s cultural preferences have on safe care?

• When staffing is inadequate, what care should be accepted or refused?

• What are other barriers to ethical practice brought about by the workplace environment?

• What does it mean to be ill or well?

• What is the proper balance between science and technology and the good of humans?

• Where do we find balance when science will allow us to experiment with the basic origins of life?

• What happens when the proper balance is in tension?

• What happens when tension exists between personal beliefs and values and institutional policy or patient desires?

No tension in balance is created in the effort to save the life of a dying healthy adolescent or set the broken leg of a healthy older adult. Science and the human good are not in conflict here. No conflict exists when there is a competent nursing staff, sufficient in number to provide quality care. However, what is the answer when modern medicine can save or prolong the life of an 8-year-old child but the child’s parents refuse treatment based on religious reasons? Or what is the answer when modern medicine has life to offer a 30-year-old mother in need of a transplanted organ but the woman is without the financial means to cover the cost of the treatment? What is the answer when an Asian family refuses to allow the physician to share news of a terminal illness with their grandmother? What is the answer when new discoveries allow some would-be parents to choose biologic characteristics of children not yet conceived? What is the answer when the emergency department is full of acutely ill patients and there are too few nurses expected for the next shift? At one end of the spectrum lies the obvious; at the other there is often only uncertainty. Health care professionals in everyday practice often find themselves somewhere between the two.

Balancing Science and Morality

If nursing care is to be competent, the right balance between science and morality must be sought and understood. Nurses must first attempt to understand not just what they are to do for their patients but who their patients are. They must examine life and its origins, in addition to its worth, usefulness, and importance. Nurses must determine their own values and seek to understand the values of others.

Health care decisions are seldom made independently of other people. Decisions are made with the patient, the family, other nurses, and other health care providers. Nurses must make a deliberate effort to recognize their own values and learn to consider and respect the values of others.

The nurse has an obligation to present himself or herself to the patient as competent. The dependent patient enters a mutual relationship with the nurse. This exchange places a patient who is vulnerable and wounded with a nurse who is educated, licensed, and knowledgeable. The patient expects nursing actions to be thorough because total caring is the defining characteristic of the patient-nurse relationship. The nurse promises to deliver holistic care to the best of his or her ability. The patient’s expectations and the nurse’s promises require a commitment to develop a reasoned thought process and sound judgment in all situations that take place within this important relationship. The more personal, subjective, and value-laden situations are deemed to be among the most difficult situations for which the nurse must prepare.

Values Formation and Moral Development

A value is a personal belief about worth that acts as a standard to guide behavior; a value system is an entire framework on which actions are based and is the backbone to how one thinks, feels, and takes action. Perhaps many nursing students come to the educational setting with a strong backbone and an intact value system. No doubt anyone living in these times has faced many situations in which important choices had to be made. The challenges faced in this generation are too numerous to avoid difficult choices. Values have been applied to those decisions. Yet often people do not take time to seriously contemplate their value system, the forces that shaped those values, and the life and worldview decisions that have been made based on them.

Examining Value Systems

To become a competent professional in every dimension of nursing care, nurses must examine their own system of values and commit themselves to a virtuous value system. A clear understanding of what is right and wrong is a necessary first step to a process sometimes referred to as values clarification, a process by which people attempt to examine the values they hold and how each of those values functions as part of a whole. Nurses must acknowledge their own values by considering how they would act in a particular situation.

Diane Uustal was one of nursing’s first leaders to describe the role of values clarification in the decision-making process of the nurse. A values clarification process (Uustal, 1992) is an important learning tool as nursing students prepare themselves to become competent professionals. The deliberate refinement of one’s own value system leads to a clearer lens through which nurses can view ethical questions in the practice of their profession. A refined value system and worldview can serve professionals as they deal with the meaning of life and its many choices. A worldview provides a cohesive model for life; it encourages personal responsibility for the living of that life, and it prepares one for making ethical choices encountered throughout life. Tools to assist the reader in values clarification can be found online (http://evolve.elsevier.com/Cherry/).

Forming a worldview and a value system is an evolving, continuous, dynamic process that moves along a continuum of development often referred to as moral development. Just as there is an orderly sequence of physical and psychologic development, there is an orderly sequence of right and wrong conduct development. Consider an adult of strong physical prowess and strong moral character. With each biologic developmental milestone, there is a more mature, more expanded physical being; likewise with each life experience that has choices between right and wrong, there is a more mature, more virtuous person.

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Nov 6, 2016 | Posted by admin in NURSING | Comments Off

Nurse Key

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Ethical and Bioethical Issues in Nursing and Health Care

Ethical and Bioethical Issues in Nursing and Health Care

Chapter Overview

Nursing Ethics

Bioethics

Dilemmas for Health Professionals

Dilemmas Created by Technology

Ethical Decision Making

Answering Difficult Questions

Balancing Science and Morality

Values Formation and Moral Development

Examining Value Systems

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