On your unit you are taking care of a 35-year-old female patient admitted in the final stages of her struggle with brain cancer. She is a single mother and has two young children at home. She received conventional and even experimental treatment, but the tumor has continued to grow. The medical team decides that further treatment would be futile. In an especially open discussion with you, she expresses her wish to explore a “do not resuscitate” (DNR) order. The attending physician reviews the clinical data and agrees that the patient is entering the terminal stages of her disease. However, in his opinion she is not ready to discuss end-of-life issues. He says that he has asked her about a DNR order, but she declines to discuss it. You suggest that he convene a family conference to discuss DNR options, but he dismisses the proposal at this time since his opinion is that the patient is not ready to participate.

Ethics is the study of conduct and character. It is concerned with determining what is good or valuable for individuals, for groups of individuals, and for society at large. Acts that are ethical reflect a commitment to standards beyond personal preferences (i.e., standards that individuals, professions, and societies strive to meet). However, when decisions must be made about health care, differing values and opinions among individuals can result in disagreement about the right thing to do, as the previous scenario illustrates. Understandable conflict occurs among health care providers, families, patients, friends, and people in the community about the right thing to do when ethics, values, and perceptions about health care collide. This chapter describes tools for you to use to embrace the role of ethics in your professional life and to participate and promote resolution when ethical dilemmas develop.

Basic Terms in Health Ethics

For a discussion of ethics, it is helpful to establish a basic vocabulary. Your understanding of the terms common in ethical discourse helps you to shape your own thoughts about ethical issues and situations and participate thoughtfully in discussions.

Autonomy

When applied to politics or government, autonomy refers to freedom from external control. Similarly in health care, respect for autonomy refers to the commitment to include patients in decisions about all aspects of care as a way of acknowledging and protecting a patient’s independence. For example, when a patient faces surgery, the surgeon has an obligation to review the surgical procedure, including risks and benefits, out of respect for the patient’s autonomy. The consent that patients read and sign before surgery documents this respect for autonomy.

Beneficence

Beneficence refers to taking positive actions to help others. The principle of beneficence is fundamental to the practice of nursing and medicine. The agreement to act with beneficence implies that the best interests of the patient remain more important than self-interest. It implies that nurses practice primarily as a service to others, even in the details of daily work.

Nonmaleficence

Maleficence refers to harm or hurt; thus nonmaleficence is the avoidance of harm or hurt. In health care, ethical practice involves not only the will to do good, but the equal commitment to do no harm. The health care professional tries to balance the risks and benefits of care while striving at the same time to do the least harm possible. A bone marrow transplant procedure may offer a chance at cure; but the process involves periods of suffering, and it may not be possible to guarantee a positive outcome. Decisions about the best course of action can be difficult and full of uncertainty, precisely because nurses agree to avoid harm at the same time as they commit to promoting benefit.

Justice

Justice refers to fairness. The term is most often used in discussions about access to health care resources, including the just distribution of resources. Discussions about health insurance, hospital locations and services, even organ transplants generally refer to issues of justice. The term just culture refers to the promotion of open discussion whenever mistakes occur, or nearly occur, without fear of recrimination. By fostering open discussion about errors, members of the health care team become informed participants, able to design new systems that prevent harm.

Fidelity

Fidelity refers to the agreement to keep promises. As a nurse you keep promises by following through on your actions and interventions. If you assess a patient for pain and offer a plan to manage the pain, the standard of fidelity encourages you to monitor the patient’s response to the plan. Professional behavior includes revision of the plan as necessary to try to keep the promise to reduce pain. Fidelity also refers to the unwillingness to abandon patients even when care becomes controversial or complex.

Professional Nursing Code of Ethics

A code of ethics is a set of guiding principles that all members of a profession accept. It is a collective statement about the group’s expectations and standards of behavior. Codes serve as guidelines to assist professional groups when questions arise about correct practice or behavior. The American Nurses Association (ANA) established the first code of nursing ethics decades ago. The ANA reviews and revises the code regularly to reflect changes in practice. However, basic principles of responsibility, accountability, advocacy, and confidentiality remain constant (Box 22-1).

Box 22-1

ANA Code of Ethics

A 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 health 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, for maintaining the integrity of the profession and its practice, and for shaping social policy.

Advocacy

Advocacy refers to the support of a particular cause. As a nurse you advocate for the health, safety, and rights of patients, including their right to privacy. Your special relationship with patients provides you with knowledge that is specific to your role as a registered nurse and as such provides you the opportunity to make a unique contribution to understanding a patient’s point of view.

Responsibility

The word responsibility refers to a willingness to respect one’s professional obligations and follow through on promises. As a nurse you are responsible for your actions and for the actions of those to whom you delegate tasks. You strive to remain competent to practice so you are able to follow through on your responsibilities reliably.

Accountability

Accountability refers to the ability to answer for one’s actions. You learn to ensure that your professional actions are explainable to your patients and your employer. Health care institutions also exercise accountability by monitoring individual and institutional compliance with national standards established by agencies such as The Joint Commission (TJC) and the ANA. Compliance officers in most health care facilities provide compliance oversight. TJC establishes national guidelines to ensure patient and workplace safety through consistent, effective nursing practices (TJC, 2011). ANA sets national standards for continuing education and curriculum development for nursing schools (ANA, 2011). TJC and ANA promote ethical decision making by requiring health care institutions to create a multidisciplinary forum, or ethics committee, for discussion of ethical issues.

Confidentiality

The concept of confidentiality in health care is widely respected. Federal legislation known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates the protection of patients’ personal health information. The legislation defines the rights and privileges of patients for protection of privacy. It establishes fines for violations (US Department of Health and Human Services, 2011). See Chapter 26 for details on HIPAA regulations governing communication of patient information contained in medical records, both hardcopy and electronic.

Values

Nursing is a work of intimacy. Nursing practice requires you to be in contact with patients physically, emotionally, psychologically, and spiritually. In most other intimate relationships you choose to enter the relationship precisely because you anticipate that your values will be shared with the other person. But as a nurse you agree to provide care to your patients solely on the basis of their need for your services. As discussed previously, the ethical principles of beneficence and fidelity shape the practice of health care and distinguish it from other common human relationships.

A value is a personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior. Inevitably you will work with patients and colleagues whose values differ from yours. To negotiate differences of opinion and value, it is important to be clear about your own values: what you value, why, and how you respect your own values even as you try to respect those of others whose values differ from yours. The values that an individual holds reflect cultural and social influences, and these values vary among people and develop and change over time. For example, in some cultures decisions about health care flow from group or family-based discussion rather than independent decisions by one person. Such a practice challenges your commitment to respect patient autonomy. Your effort to resolve differing opinions and maintain your cultural competence becomes the hallmark of your commitment to ethical practice (Box 22-2).

Box 22-2

Cultural Aspects of Care

Culturally Competent Care: End-of-Life Decisions

Research about end-of-life care shows that the standard of autonomous decision making is not necessarily universal. Some older-adult patients may defer to their children to make decisions for them as a sign of respect. Still others defer to a group elder to make decisions, even when the patient is competent to make them (Crawley, 2002). Although respect for autonomy has a strong presence in Western philosophy, especially in health care ethics, other cultures may express a preference for group process in making important decisions. For example, Pottinger et al. (2007) explain that “in some Asian cultures, the family is the smallest unit of identity and value is placed on interdependence as opposed to individualism . . . their strong desire to carry out this responsibility evokes equally strong feelings in Western health care providers who value autonomy in decision making.”

Volker (2005) summarizes findings from several surveys of patients from different ethnic backgrounds about preferences at the end of life. The goal of the surveys was to identify cultural differences so health care providers could provide more culturally sensitive care. One survey showed that European Americans, Mexican Americans, and African Americans agreed with the concept of an advance directive. However, Mexican Americans and African Americans were “less receptive” than European Americans to the need for a written advance directive. In another survey European Americans were less likely than Mexican Americans to want life-sustaining treatments at the end of life. Korean Americans were knowledgeable about end-of-life technologies but would not choose them personally.

Implications for Practice

Volker points out that research that tries to predict behaviors based on ethnicity can be hindered by the lack of uniform definitions for various ethnic groups and by the infinite variety of human beings, even if they do seem to come from a particular ethnicity or culture. Therefore culturally competent care requires respect and patience. According to Volker, the American College of Physicians proposes the following ground rules:

• Acknowledgment of and respect for cultural differences

• A willingness to negotiate and compromise when world views differ

• Being aware of one’s own values and biases

• Using communication skills that enhance empathy

• Knowing cultural practices of patient groups regularly seen

• Understanding that all patients are individuals and they may not share the same views as others within their own ethnic group

Value Formation

Development of values begins in childhood, shaped by experiences within the family unit. Variations in childrearing result in variations in values and behaviors as children grow. The fundamental urge to love and nurture children takes on different expressions within each of the wide variety of cultures in our world.

Schools, governments, religious traditions, and other social institutions play a role in the formation of values, reinforcing or sometimes challenging family values. Over time an individual acquires values by choosing some that the community holds strongly and perhaps discarding or transforming others.

Finally, individual experiences (i.e., the unpredictable twists and turns that occur in life) influence value formation. A person who suffers great loss early in life can grow to value things differently from someone whose life has been free from suffering.

Values Clarification

Ethical dilemmas almost always occur in the presence of conflicting values. To resolve ethical dilemmas one needs to distinguish among value, fact, and opinion. Sometimes people have such strong values that they consider them to be facts, not just opinion. Sometimes people are so passionate about their values that they provoke judgmental attitudes during conflict. Clarifying values—your own, your patients’, your co-workers’—is an important and effective part of ethical discourse. In the process of values clarification, you learn to tolerate differences in a way that often (although not always) becomes the key to the resolution of ethical dilemmas.

Examine the cultural values exercise in Box 22-3. The values in the exercise conflict are in neutral terms so you can appreciate how differing values need not indicate “right” or “wrong.” For example, for some people it is important to remain silent and stoic in the presence of great pain, and for others it is important to talk about it to understand and control it. Identifying values as something separate from facts can help you find tolerance for others, even when differences among you seem worlds apart.

Box 22-3

Cultural Values Exercise

The column on the right contains statements describing an opinion; the column on the left contains statements describing the opposite opinion. Neither statement is right, nor is it wrong. These statements reflect opinion, not necessarily fact. If persons from a variety of cultures were given this questionnaire, some would strongly agree with the beliefs on the right, and others with the opinions on the left. Read each statement and reflect on your own values and opinions. Circle 1 if you strongly agree with the statement on the left, 2 if you moderately agree. Circle 4 if you strongly agreement with the statement on the right and 3 if you moderately agree.

STATEMENT	RANK	STATEMENT
Preparing for the future is an important activity and reflects maturity.	1 2 3 4	Life has a predestined course. The individual should follow that course.
Vague answers are dishonest and confusing.	1 2 3 4	Vague answers are sometimes preferred because they avoid embarrassment and confrontation.
Punctuality and efficiency are characteristics of a person who is both intelligent and concerned.	1 2 3 4	Punctuality is not as important as maintaining a relaxed atmosphere, enjoying the moment, and being with family and friends.
When in severe pain, it is important to remain strong and not to complain too much.	1 2 3 4	When in severe pain, it is better to talk about the discomfort and express frustration.
It is self-centered and unwise to accept a gift from someone you do not know well.	1 2 3 4	It is an insult to refuse a gift when it is offered.
Addressing someone by his or her first name shows friendliness.	1 2 3 4	Addressing someone by his or her first name is disrespectful.
Direct questions are usually the best way to gain information.	1 2 3 4	Direct questioning is rude and could cause embarrassment.
Direct eye contact shows interest.	1 2 3 4	Direct eye contact is intrusive.
Ultimately the independence of the individual must come before the needs of the family.	1 2 3 4	The needs of the individual are always less important than the needs of the family.

Modified from Renwick GW, Rhinesmith SH: An exercise in cultural analysis for managers, Chicago, 1995, Intercultural Press.

Ethics and Philosophy

Historically health care ethics constituted a search for fixed standards that would determine right action. Over time ethics has grown into a complex field of study, more flexible than fixed, filled with differences of opinion and deeply meaningful efforts to understand human interaction. The following review introduces to you a variety of philosophies that you may encounter during ethical discussions in health care settings.

Deontology

A traditional ethical theory, deontology proposes a system of ethics that is perhaps most familiar to health care practitioners. Its foundations come from the work of an eighteenth-century philosopher, Immanuel Kant (1724-1804). Deontology defines actions as right or wrong based on their “right-making characteristics” such as fidelity to promises, truthfulness, and justice (Beauchamp and Childress, 2008). It specifically does not look to consequences of actions to determine right or wrong. Instead it examines a situation for the existence of essential right or wrong. For example, if you try to make a decision about the ethics of a controversial medical procedure, deontology guides you to focus on how the procedure ensures fidelity to the patient, truthfulness, justice, and beneficence. You focus less on the consequences (ethically speaking). If an act is just, respects autonomy, and provides good, it will be right, and it will be ethical according to this philosophy. Deontology depends on a mutual understanding and acceptance of these principles.

Often people in ethical dilemmas have to choose between conflicting principles. For example, application of the principle of respect for autonomy is sometimes confusing when dealing with children. The health care team may recommend a certain course of treatment, but the parent disagrees or even refuses the recommendation. Whose autonomy should receive the respect—the parent’s? Who should speak for the child’s best interest? Communities struggle to decide who ultimately is responsible for the well-being of children. A commitment to respect the “rightness” of autonomy is a guiding principle in deontology, but adherence to the principle alone may not provide clear answers to ethical dilemmas.

Utilitarianism

A utilitarian system of ethics proposes that the value of something is determined by its usefulness. This philosophy is also known as consequentialism because its main emphasis is on the outcome or consequence of action. A third term associated with this philosophy is teleology, from the Greek word telos, meaning “end,” or the study of ends or final causes. John Stuart Mill (1806-1873), a British philosopher, first proposed its philosophical foundations. The greatest good for the greatest number of people is the guiding principle for determining right action in this system. As with deontology, utilitarianism relies on the application of a certain principle, (i.e., measures of “good” and “greatest”) (Beauchamp and Childress, 2008). The difference between utilitarianism and deontology is the focus on outcomes. Utilitarianism measures the effect that an act will have; deontology looks to the presence of principle regardless of outcome.

People have conflicting definitions of “greatest good.” For example, research suggests that education about safe sex practices reduces the spread of human immunodeficiency virus (HIV). Reducing incidence of HIV is good for a great number of people. For some, education about sex is best provided within a family setting rather than in school because it promotes family values. However, for others the greater good is educating the greatest number of people in the most effective way possible; therefore sex education in the public schools would ensure the greatest good. As with deontology, utilitarianism provides guidance, but it does not guarantee agreement.

Feminist Ethics

Feminist ethics critiques conventional ethics such as deontology and utilitarianism. It looks to the nature of relationships to guide participants in making difficult decisions, especially relationships in which power is unequal or in which a point of view has become ignored or invisible (Brody, 2009). Writers with a feminist perspective tend to concentrate more on practical solutions than on theory.

Feminist ethicists propose that the natural human urge to be influenced by relationships is a positive value. Critics of feminist ethics are concerned about the lack of focus on universal principals. Without guidance from universal principals, they argue, solutions depend completely on the situation itself.

Ethics of Care

The ethics of care and feminist ethics are closely related. Both promote a philosophy that focuses on understanding relationships, especially personal narratives.

An early proponent of the ethics of care, Nel Noddings (1984), used the term the one-caring to identify the individual who provides care, and the cared-for to refer to the patient. In adopting this language Noddings hoped to emphasize the role of feelings. Contemporary writers such as Virginia Held (2005) continue to build on Noddings’ foundations by making a case for a focus on the fundamental nature of relationships in understanding ethical issues. Ethics of care may even address issues beyond individual relationships such as ethical concerns about the structures within which individual caring occurs such as health care facilities.

Consensus in Bioethics

Bringing different points of view to agreement and harmony, or consensus, requires skill and patience. Building consensus is essentially an act of discovery, in which “collective wisdom” guides a group to the best possible decision. It encourages respect for unusual points of view while striving for agreement among all participants (Dressler, 2006). As a strategy for solving dilemmas, consensus building promotes respect and agreement rather than a particular philosophy or moral system itself. In the example of the processing of the ethical dilemma described in this chapter, the process is basically one of consensus building.

Nursing Point of View

All patients in the health care system interact with a nurse at some point, and they interact in ways that are unique to nursing. Nurses generally engage with patients over longer periods of time than other disciplines. Because nurses are involved in intimate physical acts such as bathing, feeding, and special procedures, patients and families may feel safer or more comfortable in revealing information not always shared with physicians, health care providers, or others. Details about family life, information about coping styles, personal preferences, and details about fears and insecurities are likely to come out during the course of nursing interventions. Your ability to recognize these aspects of a patient’s situation and express your professional concerns accordingly provides critical value to the discussion.

On the other hand, it is important to remember that care of any patient involves many disciplines. Managers and administrators from many different professional backgrounds contribute to ethical discourse with their knowledge of systems, distribution of resources, financial possibilities, or limits (Fig. 22-1).

FIG. 22-1 Nurses collaborate with other professionals in making ethical decisions. *Copyright © (2007) (Copyright 2007 Jupiter Images Corporation.).*

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Tags: Fundamentals of Nursing

Nov 17, 2016 | Posted by admin in NURSING | Comments Off

Nurse Key

Fastest Nurse Insight Engine

Ethics and Values

Ethics and Values

Objectives

Key Terms