Ethical Dimensions of Nursing and Health Care



Ethical Dimensions of Nursing and Health Care


Heather Vallent, RN, MS and Pamela J. Grace, PhD, APRN



OBJECTIVES


At the completion of this chapter, the reader will be able to:


• Describe the foundations of ethical nursing practice.


• Identify the ethical content of everyday practice situations.


• Analyze difficult practice and health care problems using a moral reasoning framework.


• Use appropriate strategies and resources to address practice problems.


• Delineate the scope of nursing’s responsibilities for ethical care environments.



PROFILE IN PRACTICE



My interest in ethics started as an undergraduate nursing student when I double-majored in philosophy. At the time, it seemed foolish—What was a nursing student doing studying philosophy? The joke was that as a student, I just spent more time asking “Why?” about everything. The necessity of understanding ethics became much more obvious to me in my first year working as a registered nurse.


As a new graduate, I was grappling with many tasks and technical issues. One of the hardest things for me to learn was how to deal with the unpredictable, especially death and dying. Unfortunately, that first year, I had many experiences with dying patients. Dealing with death and dying has never become an “easy issue,” but it was especially difficult as a brand-new nurse. Such questions as “Did I do right by my patient or their family?” or “How could this have been done better for all?” kept me perplexed for a long time. Once I was able to identify where my angst was coming from, I began to organize my thoughts, but I still needed an outlet to process them. My philosophy background helped me do this. I knew that I wanted to do “good” for my patients, but it took some time to fully understand that doing “good” does not always yield good results.


In my first year, I also saw first-hand what was meant by a scarcity of resources and the effect this has on the patient, the patient’s family, and also the nurse. The desire to do good was further complicated by the fact that I could not always be perfect and that doing good for one patient sometimes seemed to mean not doing as good for another. For example, a very sick patient on my general medical floor may have been too sick to be on that floor and ideally would have had an ICU bed; yet there were no patients in the ICU well enough to leave the unit and relinquish their bed to my sick patient. So, if my patient could not be moved to the ICU, where there was a better chance of “fixing” the patient, the problem then became doing the best job I could to help this patient, even though this was not the best-case scenario. Understanding the idea of scarcity of resources can often mean that doing justice is compromised. It definitely takes time to realize that “best” cannot always be achieved if there is a desire to do “good” for all. Over time, my understanding of ethics helped me to realize this and gave me the tools to move forward as an advocate for change.


After a few years of working as a staff nurse at Massachusetts General Hospital (MGH) in Boston, I decided to pursue my MS degree at Boston College. During graduate school, I took an advanced ethics course, where I was given more knowledge and resources to continue my interest in ethics and begin my journey toward becoming a nursing ethics expert. One of my CNS clinical practica was with a very knowledgeable nurse ethicist at MGH, Ellen Robinson, RN, PhD. Learning from Dr. Robinson was truly an enlightening experience. The majority of our consults were spent resolving conflicts around end-of-life care. Since then, I have also become a member of MGH’s Optimum Care Committee (OCC). This committee provides consultation for difficult patient cases and ethical dilemmas. Being surrounded by such great ethical minds inspires me to continue asking myself, “What is the ethical good for each—and for all—of my patients?”





imageOverview of Ethics


Ethics is a form of philosophy that has many implications for everyday use, especially when exploring very complex issues. It is derived from the Greek word ethos, which is roughly interpreted as “character.” The term ethics can be used and interpreted in many different ways. In a broad sense, ethics is an attempt to establish a foundation (or a philosophical inquiry) for what determines good conduct in human behavior. When it is used to describe an action, it denotes the ability to know what is right and wrong—and then to act on the right. Ambiguity exists not only in the practice of ethics, but in the word itself.


When discussing the conduct of a whole group, the term ethics is used; however, when referring to an individual, it has become common practice to use the term morals. Ethics is synonymous with moral philosophy; they are simply derived from two different languages (ethics from Greek; morals from Latin). Essentially, morals become your personal ethics.


Many famous philosophers (e.g., Plato, Aristotle, Immanuel Kant, David Hume, Thomas Hobbes, John Stuart Mill, Friedrich Nietzsche) have debated what constitutes a moral action and a moral person. From these debates, many “guidelines” have been developed to evaluate a person’s or a group’s ability to act on a moral philosophy. Subsequently, many professions, including nursing, have developed their own “code of ethics” to determine whether a member of the profession demonstrates moral reasoning.



imageFoundations of Ethical Nursing Practice


MORAL PHILOSOPHY


Moral philosophy is the pursuit of understanding human values (doing ethics). So what are values? Values are a way to qualify an action. Morally good choices must be supported by good reasons and must take into consideration other individuals, with impartiality (Rachels, 2007). Many philosophers have dedicated their life to defining the complexities of moral theory. Some variations include deontology, the concept that we should act according to a perceived duty, and utilitarianism, the idea that we ought to maximize the greatest good for the greatest number. Such theories arose out of the needs and struggles of particular eras and as such are useful to varying degrees in general life. It is beyond the scope of this chapter to discuss the complexities of such theories.


The various moral theories do provide some structure and perspective regarding the underlying concern; however, they are complicated and all are to some degree flawed or have been criticized as such. For this reason, in health care settings, we do not rely on any one moral theory to give us answers to a problem. As Grace (2009) states, “We must understand the limits of the theory and what its flaws are, rather than uncritically relying on theories to answer difficult issues in health care” (p. 13).


Moral philosophy can be utilized as a framework or thought process from which to decide which actions are appropriate. For example, imagine a nurse named Molly, who has made a mistake that has not caused harm to a patient but could have. Should Molly report this error to the patient and/or the physician? The debate that is going on in Molly’s head (Should she report her error or ignore it? What are the consequences either way?) is Molly doing moral philosophy. From her thought process, Molly will pursue an action; this is Molly doing applied ethics.



APPLIED ETHICS


Applied ethics is the application of the thoughts determined by moral reasoning. It is not enough to know what is good and what is the right thing to do; the ethical person needs to be able to act on his or her thoughts. This is often not an easy thing to accomplish. There are many people in this world, all of whom have a position on what they consider the right thing to do. One individual’s version can easily conflict with another’s: “Similarly, there is no reason to think that if there is moral truth everyone must know it” (Rachels, 2007, p. 11). Furthermore, what about the possibility that not all people are even capable of moral reasoning?


A more complex task is establishing the right conduct for a group of people engaged in the same work—individuals who should have the same goals in mind. This is especially true of groups who provide an important societal service. The group needs to come to consensus on what they consider ethical actions. In order to remain as part of the group, each individual is responsible for good actions as conceptualized by the thought process of the whole. Such a group distinguishes themselves by their idea of applied ethics, thus forming a branch of applied ethics. Individual branches are termed professional ethics.



PROFESSIONAL ETHICS


To be considered a true profession, nursing must have a code of ethics from which to practice. A professional code acts as a guide to what the profession considers professional conduct and the scope of its practice.


It may seem obvious at this point that different professions are going to follow different codes of conduct based on the goals and duties of their particular professions. For comparison, let us explore the difference between business ethics and nursing ethics: it would likely not be ethical for a businessman to ask a client to undress for the purpose of clarifying his or her needs; however, it could be very normal for a nurse to ask a patient to undress (while maintaining the patient’s dignity) in order to gain data to clarify his or her needs. A different profession, a different setting, and a different relationship exist between the businessman and client and the nurse and the patient. It is this difference that greatly determines what constitutes an ethical action. Whether an action is considered ethical or nonethical is partially dependent on the goal of the profession.



NURSING ETHICS


To explore nursing ethics more specifically and to distinguish nursing ethics from health care ethics or medical ethics, we need to understand the professional goals of nursing and how these relate to promoting individual and societal good. According to Nightingale, nursing “ought to signify the proper use of fresh water, light, warmth … all at the least expense of vital power to the patient” (1969, p. 8). The means to this goal is complex; a nurse utilizes his or her own knowledge base, experience, personal limitations, a general understanding of ethics, and many other attributes to promote the good for the patient. Furthermore, “it is the discipline’s explicit aim of contributing both to the health of individuals and the overall health of society that makes nursing itself a moral endeavor” (Grace, 2009, pp. 52-53).


We can think of nursing ethics in two different ways—a form of study that looks at nurses’ responsibilities or nurses’ actual practice of doing good (Grace, 2009). In Fry (2002), the main concerns for nursing ethics are the ability to describe the characteristics of the “good” nurse and to identify nurses’ ethical practices. From this we can deduce that the idea of the ethical nurse is one who can or does recognize a potential problem that must be differentiated as morally right or morally wrong. This struggle between right and wrong is often convoluted by the fact that rarely is one option completely right and another completely wrong; instead, we experience the inevitable gray area. For example, Mike, who lives with his family in a small but well-populated town, has tuberculosis, a highly contagious respiratory disease. Within the town, there is only one small hospital. Unfortunately, all of the hospital beds are currently occupied with very sick townspeople. Should Mike be admitted to the hospital, where he could be isolated to prevent him from spreading TB to his family, but thereby causing one of the very sick townspeople to be discharged prematurely from the hospital? Or should Mike stay at home with his family without precautions, thus exposing his family members to serious illness, but not displacing any current patients in the hospital? What would a “good” nurse do in this situation? Does a straightforward answer to this question even exist? To further expand on this thought, consider that the patient may not represent one individual, but rather a family or even a whole community or society at large. In moral reasoning, when neither option is ideal, the resulting gray area is called a dilemma.


Abma and colleagues (2008) have reviewed multiple approaches to defining the characteristics of the “good” nurse or “good” care. From their research they have summarized that the concept of the “good nurse” is an outcome of a nurse’s reflective inner dialogue with other nurses and health care members, as well as with patients (i.e., “thinking through” a hypothetical conversation between oneself and others). They found that nurses, by engaging in these dialogues, “develop richer understandings of their practice” (Abma et al., 2008, p. 790). They postulate that if nurses are allowed the time for this reflective inner dialogue, then the attributes of a “good nurse” will develop over time, growing with each experience encountered and improving practice. Embodying these characteristics, a morally good nurse would be able to identify a problem, to articulate why it is a problem, to determine how a nurse would be affected by this problem, and to determine how the patient would be affected by this problem. Presumably, this would be followed by good action.


For the good nurse to be able to identify all of these issues, a framework or a body of knowledge is required that can help the nurse decipher and process the problem. A nurse’s knowledge base is broad and draws on theories and evidence from a multitude of disciplines. This knowledge is filtered through the nursing perspective as developed over time by nursing’s scholars and clinicians. Nursing’s perspective is that human beings are unique, complex, and contextual. This perspective plus the goals of the profession related to facilitating health and relieving suffering provide a framework that allows us to appraise nursing actions. Nursing actions, then, are ethical if they use knowledge and skills to provide good nursing care, This precedent then essentially becomes a moral responsibility for the nurse to expand upon nursing’s goals of practice not only in individual situations but also in the interest of good practice as a whole (Grace, 2009). That is, good (ethical) nursing actions include addressing the source of obstacles to good practice that may arise from any levels of the health care system.



Nursing Ethics History


Historically, nursing ethics was more concerned with the nurse’s personal behavior or virtues instead of his or her professional behavior (Fowler, 1997). An ethical nurse was one who was obedient and followed orders (Fry, 2002). According to Fowler (1997), in the late 1960s, nursing ethics evolved, along with general changes in society, to a more duty-based ethics, in which nurses were held accountable for their actions. However, Fowler argued that nursing ethics should be a combination of virtue-based and duty-based ethics; that is, nurses should be concerned not only with their actions, but also with the environment in which they practice.


With this new sense of accountability, nursing needed guidelines from which to demonstrate ethical care. This concept of needing a code upon which to base nursing actions started in Detroit, Michigan, in 1893 with Lystra Gretter, who wrote the Nightingale Pledge. In 1896, a group of nurses formed an organization that later came to be known as the American Nurses Association (ANA). The group began the process of developing a code of ethics for nursing at that time, although the ANA did not formally accept a code until 1950. Since then, there have been several published revisions; the latest, Code of Ethics for Nurse with Interpretive Statements, was released in 2001 (Box 12-1).



BOX 12-1   ANA’s Code of Ethics for Nurses, 2001




1. 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.


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


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


4. 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.


5. 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.


6. 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.


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


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


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


Reprinted with permission of American Nurses Association, Code of Ethics for Nurses with Interpretive Statements, © 2001 Nursesbooks.org, Silver Spring, MD.


The International Council of Nurses (ICN), a federation of national nurses’ associations serving nurses in more than 128 countries, also published a code of ethics in 1953, with its most recent revision appearing in 2006 (ICN, 2006). Any code of ethics is established to protect the population it serves and to uphold the goals of the profession. Although many health care professions have similar goals, the perspective on how these goals can be met and the context in which the individual professions practice lead to profession-specific codes of ethics.



Nursing Ethics Professional Values


The nursing profession has identified with the practice of ethics for years. As Fowler (1997) stated, ethics “has been the very foundation of nursing practice since the inception of modern nursing in the United States in the late 1870s” (p. 17). Implicit in the idea of having a Code of Ethics (2001) is the understanding that all actions of the individual nurse reflect on the actions of the nursing profession as a whole; therefore all actions should be congruent within the context of the Code. If any action by the nurse does not allow for the goals of the Code (Principle 1), then it is nursing’s obligation to fix this (Principle 10). It is in the best interest of nursing students to familiarize themselves with the Code and to reflect on its statements throughout their years of practice.


Appropriate to ask at this time is, “Who determines what constitutes a good action? And what if I do not agree?” We are all born into different cultures and are subject to different social standards, not to mention different religious perspectives. So how can we be expected to all agree on the concept of “a nurse’s good action”?



Research on Nursing Ethics


Nursing has conducted its own research on its practice conduct. As society has changed over time, so has the nursing profession. With the advent of increasing responsibility and technological growth, the nursing profession’s ethical inquiry has evolved. The scope of knowledge developed from research on nursing ethics continues to shape the trajectory of our profession’s future.


Before discussing nursing’s research on ethics, it is necessary to review the historical aspects of the ethics surrounding research on human subjects. It is important to understand that all research is subject to ethical scrutiny. For a brief history of research ethics and human subject protection, refer to Box 12-2. Only by reviewing this history can one comprehend the growth that has occurred in this field.



BOX 12-2   Overview of Research History in Relation to Ethics


When discussing ethics in relation to research, it is important to mention a few very important historical cases that have shaped biomedical ethics of today. The Nuremberg Code was enacted in 1949, after reviewing the experiments taken place in Nazi Germany. This Code stated that the protection of the research subject is always more important than any potential benefit to society and most important, the voluntary participation of the research subject should be sought. The World Medical Association (WMA) developed the Helsinki Declaration in 1964 as a follow-up to the Nuremburg Code. It was realized that ensuring voluntary participation, as required by the Nuremburg Code, meant that research could not be carried out on children or the cognitively incapacitated; yet research with the potential to benefit these groups is important. Concepts that the WMA considered in more detail included therapeutic versus nontherapeutic experiments, consenting minors, and consent by proxy (substitute).


Even with the advent of the Helsinki Declaration, many unethical research studies continued. In the 1960s the Willowbrook Hepatitis Studies intentionally injected hepatitis into “mentally retarded” children who resided at Willowbrook School. The Stanford Prison Experiment by Zimbardo in 1971 explored the psychological effect that imprisonment would have on college students. In 1972, the media publicized the unethical practices of the Tuskegee Syphilis Study, in particular the lack of informed consent and the lack of full disclosure of information. From all of these horrific “studies” came the development of the National Research Act of 1974 (Grace, 2009).


The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research was created as a result of the National Research Act. This commission published the Belmont Report in 1979. The Belmont Report provided a framework for the establishment of three ethical principles—respect for persons, beneficence, and justice. By identifying these principles, the Belmont Report also established boundaries between the practice of research and the practice of medicine, determined the criteria for risk versus benefits to the subjects, developed guidelines for the selection of participants, and defined the concept of informed consent (National Institutes of Health, Office of Human Subjects Research, 1979). Another important outcome of the Belmont Report was the origin of independent review committees, also known as institutional review boards (IRBs). IRBs ensure the ethical conduct of the research for any institution that is funded by the U.S. government (Grace, 2009).


From this brief review of historical events, it is clear why research on humans has significant implications for ethics and how promoting human good can be lost in the actual science. Utilizing the knowledge gained from unfortunate, sometimes devastating, historical choices, ethical practices related to research has taken on a new meaning.


The concept of ethics in research has evolved over time with the change in nursing’s responsibilities, as discussed in the history of nursing ethics. In the early 1900s, the aim of studying nursing ethics was to gain clarity on nurses’ behavior and conduct in caring for the sick (Fry, 2002). After World War II, more nurses attended college and became more independent and accountable for their own clinical judgment (Grace, 2009). By the 1990s the topics explored by nurses had increased; however, Tschudin (2006), who served as editor of Nursing Ethics since its inception in 1994 until 2008, undertook a content review of the articles published over the first 10 years. She noted that initially the articles were “timid” and not particularly in-depth, but rather focused more on facts or legal issues without taking a stance on the issue. However, by 2003, many articles emphasized care and virtue ethics influenced by an intuitive response and with an affirmation of their beliefs. Some similarities throughout the 10 years of publication included the analysis of end-of-life care, nursing education, morality, moral decision making, and carrying out research (Tschudin, 2006). Contemporary nursing ethics analyzes nursing’s ability to meet the profession’s established goals. More emphasis is placed on virtue ethics and the intuitive process, rather than conduct and laws: “Nursing ethics remains a subject that will change and grow with what is given and taken, tried and not tried, and used or not used” (Tschudin, 2006, p. 74).



imageEthical Nursing Practice


From our previous discussion, we can now say that ethical nursing practice is in fact the same thing as good nursing practice. A nurse is practicing well when that nurse uses knowledge, experience, skills, and an understanding of the patient as a unique individual in order to facilitate that patient’s well-being. That is, the nurse uses these characteristics to meet nursing goals. However, in today’s health care settings and environments of care, nurses may not always be able to carry out those actions that will best meet their patients’ needs. They are often faced with barriers to giving the care that they believe is important and necessary. Additionally, nurses may sometimes be confronted with situations in which it is not obvious what is actually in the best interests of patients and their families. Under such circumstances, there are further questions about how to proceed and what are likely to be the best or most effective actions. This next section provides foundations and resources for nurses as they try to give good care to patients in difficult situations. Responsibilities exist at two levels. The first and priority level is to meet the immediate needs of patients and families. The second level of responsibility is to address the unit, institution, or public policies that are unjust or do not serve patients and/or the public well.



PERCEIVING ETHICAL CONTENT


Studies have shown that nurses sometimes do not understand that ethics is infused throughout all of their professional activities. For example, from an extensive survey (N = 2090) of nurses in the New England region who were asked about ethical issues encountered in practice, a small but significant proportion responded that they either never encountered ethical issues in the course of their work or that they rarely did (Grace, Fry, & Schultz, 2003). Additionally, in a research study that the authors of this chapter conducted related to understanding what experienced nurses see as essential characteristics of good nurses, some interesting themes are emerging as data are analyzed. This qualitative phenomenological study provides some tentative support for the idea that good nurses take all of their nursing role–related activities to be ethical in nature. Nurses who were not deemed “good nurses” by the respondents tended to focus on completing the day’s tasks in a timely manner rather than being responsible for their patients’ individual needs. Developing a nurse-patient relationship, when this is possible, tends to weaken the task-orientation of nurses and strengthens the focus on providing good care. This focus on the interests of the particular individual and his or her unique needs has long been considered part of the nurse’s caring function.


The nurse-patient relationship, like the physician-patient relationship, has been described as fiduciary in nature (Grace, 1998, 2009; Spenceley, Reutter, & Allen, 2006; Zaner, 1991). What this means is that the person who presents to us in need of health care is vulnerable as a result of their needs. They are relying on us to work toward meeting their needs and are counting on us not to be distracted by other issues. They are hoping, if not expecting, that their interest remains our most important concern. This places a heavy burden on nurses who often practice within institutions and settings that limit their actions. Many nurses see this as too much to ask. Any number of things might influence their ability to do best for a given patient. Consider a few examples: staffing is poor, and the nurse is forced to juggle the care needs of several very critical patients; the institution is trying to cut costs and does not have the best drug or the most effective monitoring equipment for the patient; changes in health care system financing lead to shorter lengths of stay (LOS), and patients are often released home before they are ready; a frail, elderly patient is sent home with no capable adult available to provide the needed care.


In addition to institutional constraints on good care, the nurse may be experiencing difficulties in his or her personal life, may be emotionally or physically exhausted, or may be suffering from residual “moral distress.” First described by Jameton (1984) and later studied by other scholars (Corley, 2002; Corley, Minnick, Elswick, & Jacobs, 2005; Eizenberg, Desivilya, & Hirschfeld, 2009; Mohr & Mahon, 1996), moral distress is a feeling of unease that accompanies the inability to do what one knows to be right. Left unaddressed, moral distress can have long-lasting effects on people and has been shown to cause nurses to leave nursing. Nurses who remain may distance themselves from and cease to engage with patients. Both of these actions, leaving nursing and failing to interact with patients, are thought to be defense mechanisms that nurses have used to cope with moral distress. Here are some common examples of situations that can lead to a nurse’s distress: the seemingly uncaring attitudes of one’s colleagues, physicians who do not listen to a nurse’s account of what the patient wants, families who disagree about what treatments a patient should have, and so on.


Although nurses sometimes feel powerless to do the right thing under difficult conditions, there are appropriate and effective paths of recourse. Learning how to evaluate complex issues and analyze aspects of difficult cases with personal reflection and dialoguing with others (Abma et al., 2008) is one way to come to terms with and diffuse moral distress. Taking action to remedy a problem is a further way to disperse residual feelings of moral distress. However, before appropriate action can be identified and taken, we must understand our professional obligations as nurses.


The ANA’s Code of Ethics for Nurses (2001) has clearly articulated the professional obligations for nurses in the United States. These obligations are all rooted in the goals that nursing as a profession has determined over time by nursing scholars and practicing nurses. The goals are concisely articulated in the ANA’s Social Policy Statement (2003):



Understanding disciplinary goals and our responsibilities to further them is a first step in responding appropriately to the needs of our patients. The second step is to use our knowledge, experience, and skills (clinical judgment) to grasp the unique needs of the particular patient. The third step is to give them the care required or access the appropriate resources so that their needs can be met. Implicit in this process is the idea that we understand the limits of our own knowledge and skills and consult with others as necessary.


But what is the extent of our responsibility when obstacles to good care are present or when it is unclear what is the right action in a complex case? At that point, we need to use the tools of ethical decision making to gain clarity about the issues and, in doing so, try to uncover and propose appropriate courses of action, all the while utilizing appropriate resources.



Decision-Making Tools


What is a decision-making tool? It is a helpful framework or structure for working through a difficult problem. Figure 12-1 is a schematic approach to visualize the many elements that are involved in moral decision making. There are many decision making frameworks available in both nursing and ethics textbooks. The one used in this chapter is synthesized by one of the authors (Grace) from her clinical and educational experiences and the extant literature, and it is presented later in the chapter.


image
FIGURE 12-1 Essentials of moral decisions and actions in nursing practice.

Although they are called frameworks, decision making tools do not always proceed in a direct line but rather pose questions to be answered, forcing us to ask more questions and to seek out more information. They will cause us to weave back and forth through the information until we have exposed as many aspects of the issue as possible. Such frameworks help us see the hidden aspects of a case or problem. They do not necessarily give us the “right” answer. There are sometimes no clearly right answers. The reason for this is that we are dealing with human beings and cannot absolutely predict the outcome. We can, however, often be reasonably sure we are on the right track. This is what decision-making tools do for us: they help us deliberate about the issue so that we can gain confidence about available courses of action. They keep us focused on the main goal of action. For the most part, in practice this will be an individual human being, although the needs of family members may also be important considerations. In working through a situation, it is often helpful to involve others. These different perspectives can shed light on hidden aspects and illuminate solutions not previously considered.


Using an ethical decision-making tool does require a basic understanding of the language of health care ethics. Grasping the meaning of generally accepted ethical principles helps with decision making in two ways: it helps us isolate problematic issues and it helps us articulate these issues in language that is understood by other professionals. This next section explores the origins and meaning of ethical principles and uses clinical examples to illustrate their meaning. The practice of analyzing complex cases using decision-making tools is common in health care ethics committees and in education settings. The purposes of case analyses are clarity, direction, and learning from experience. The goals are to determine the best (beneficent) actions and to minimize harm (nonmaleficence). The main focus is the good of a particular human being; a secondary focus is the good of other human beings who may be affected by decisions made. As a professional nurse who has knowledge of ethical decision making, you will be equipped to start your own ethics discussion group on your unit and to serve as a resource for other nurses.



What Are Ethical Principles?


Ethical principles are “rules, standards, or guidelines for action that are derived from theoretical propositions … about what is good for humans” (Grace, 2009, p. 17). More simply put, they are statements that capture what humans have over time come to believe is important in ensuring a reasonably good life for individuals living within mutually beneficial societies. Societies are, of course, made up of individuals who work together to meet collective needs. No one person is capable of solely providing for his or her own needs. Ethical principles have their roots in different philosophical points of view, but historically they have come to be seen as useful for “imposing order on a situation, highlighting important considerations in problem-solving complex issues” (Grace, 2009, p.17) and holding people accountable for their treatment of others. They are reflective of cultural, religious, and social values, and thus different cultures may stress certain principles over others.


Ethical principles themselves, many of which derive from moral theory, have proven useful in providing clarity and in bringing out underlying assumptions that are being made in a situation. For example, in the Western world, autonomy is often viewed as the most important principle, whereas in other cultures social harmony may be seen as more important than an individual’s right to make his or her own decisions. This next section discusses the four principles (beneficence, nonmaleficence, justice, and autonomy) that Beauchamp and Childress (2008) highlighted, as well as some other concepts that have been seen as important in enabling good nursing practice.


Ethical principles serve as a “beginning or starting point for reasoning” (Thompson, Melia, & Boyd, 2000, p. 13). They are not absolutes. That is, no one principle will lead to the right action in every circumstance, because they are derived from a variety of ethical theories and perspectives over time. Consequently, principles that have proven helpful to ethical reasoning in health care settings can conflict with each other. It is important to keep this in mind because we may have to choose which principle to favor in a given situation. This decision most often will depend on the particular situation and the goals for the main focus of the decision making—most often an individual patient.


Ethical principles, however, are helpful in providing clarity about the salient issues to consider in a problematic situation. They trigger more questions and permit the revelation of underlying assumptions. Thus ethical principles are the most helpful in the analysis phase of the problem-solving process. They help determine the most critical issues, such as what is at stake and for whom. Beauchamp & Childress (2008) have stated that ethical principles are action guides to moral decision making and are an important element in the formation of moral judgments in professional practice. For nurses, our overriding action guide is the “good” of the patient in front of us. This idea is captured by the principle of beneficence.



Beneficence


Beneficence is the obligation to provide a good. When nurses enter the profession and start to practice, they are essentially promising that they can provide a good. If there were no benefit that nurses could bring to patients, there would be no need for nurses. In broader terms, beneficence means that not only are we as nurses obliged to provide a good, but we are charged with avoiding harm as a byproduct of our good actions. In health care ethics language, acting on this principle means helping others to gain what is of benefit to them. However, in order to do this, we must understand what benefit means in terms of others’ (patients’) desires and needs. The obligations of beneficence, then, are stronger for the nurse when acting as a nurse than when acting as a citizen in everyday life. This is because the purposes and goals of nursing are explicitly to provide for the patient’s good. The ANA’s Social Policy Statement affirms nursing’s commitment to provide “safe, effective, quality care” (ANA, 2003, p. 1). The goals of nursing are generally understood to be “the prevention of illness, the alleviation of suffering, and the protection, promotion, and restoration of health” (ANA, 2001, p. 5). All of these services are “goods” because they address critical human needs; thus the goals of nursing are beneficent goals.


Applying the principle of beneficence in nursing practice, though, may not be as simple as it sounds. For example, is the nurse obliged to consider all the ways in which the patient might be benefited? What should the nurse do if obstacles exist to giving good care that are beyond his or her immediate control? A second problem in applying this principle is deciding whether the obligation to provide benefit is stronger than the obligation to avoid harm. Some ethicists claim that the duty to avoid harm—also known as the ethical principle of nonmaleficence—is a stronger obligation (at least in contemporary health care relationships) than the obligation to benefit (Beauchamp & Childress, 2008). This opinion has risen, in part, because we now have powerful biological and technological advances that can be used to treat or save critically ill patients, but these tools can also have extreme side effects.


Nonmaleficence must be balanced by the provision of benefit, and acceptable ranges of both benefits and risks of harm need to be established. For example, getting a patient out of bed after surgery is likely to cause pain despite premedication with an analgesic. Nevertheless, mobilization is still encouraged because we know that in the long run more good than harm is likely to be achieved. Another example is the availability of tests that can highlight a person’s genetic susceptibility to develop a disease such as cancer. Although genetic testing can provide positive benefits (e.g., relieving a person’s anxiety if the test gives a negative result or facilitating early intervention if the test yields a positive result), such testing can also cause extreme anxiety, depression, and guilt. Nurses need to anticipate these concerns when asked for advice or when counseling patients.


A third problem in applying the principle of beneficence in nursing practice concerns the limits of providing benefit to patients. At what point do benefits to other parties (one’s own family, the employing institution, co-workers) take priority over the benefits to the patient? Is the nurse obliged to provide benefits broadly or simply to the specific patient? Nurses need to be clear about the boundaries of their obligation to provide benefits and avoid harm in patient care. More examples of this follow later in this chapter.



Justice


Another consideration in ethical decision making is how benefits and burdens should be distributed among patient populations (Fry & Veatch, 2006). Nurses generally care for several patients during any given shift. A decision may have to be made about what is a just or fair allocation of resources among patients under the nurse’s care. Should the priority be based on the greatest need, the sickest patient, or the patient most likely to recover? In addition, nurses are also often faced with the end results of unjust social arrangements. In the United States, we see quite often very sick patients who do not have easy access to, or cannot afford, preventive health care or health-promoting care. This puts these patients at a disadvantage in many ways and causes harm in the sense that they do not seek care early in their illness. Consequently, these patients’ illnesses may likely become more severe and result in irreversible damage.


The principle of justice is likely to lead nursing to work towards change. Both the ANA’s Code of Ethics (2001) and the ANA’s Social Policy Statement (2003) highlight the nurse’s responsibility to join with others and address inequities at the institutional and societal level. In A Theory of Justice, Rawls (1971) hypothesizes that those who are the least advantaged in terms of possessing material goods and/or personal abilities should receive the most benefit from social structures that serve the public. When this does not happen, Rawls argues, nurses and other health care providers who see first-hand the results of these inequities have a responsibility to act to change the situation. A further discussion of health care disparities occurs in Chapters 14 and 19.


Currently, health care arrangements in the United States cannot be described as just, because many individuals are uninsured and have inadequate access to health care. The U.S. Census Bureau, in 2007, estimated that more than 45 million Americans were without health insurance (DeNavas-Walt, Proctor, & Smith, 2008). Nurses are among those who are the most likely to see the effects of poor health monitoring and maintenance on the severity of their patients’ illnesses. Nurses thus have responsibilities for social and political activism related to ensuring just health care. Provision 8 of the ANA’s Code of Ethics for Nurses (2001) delineates nursing’s responsibilities to be collectively active in promoting societal health (see Box 12-1). Socioeconomic factors and roles of the professional nurse are also addressed in Chapters 7 and 4, respectively.

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Oct 26, 2016 | Posted by in NURSING | Comments Off on Ethical Dimensions of Nursing and Health Care

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