1
Recognizing Ethical Terms, Theories, and Principles
CRAIG M. KLUGMAN
LEARNING OBJECTIVES AND OUTCOMES
Upon completion of this chapter, the reader will be able to:
Define ethics, morality, and law
Understand the history of nursing ethics and bioethics
Determine if a case has an ethical component
Describe Rest’s four components of moral competence
Analyze ethical dilemmas using ethical theories
Apply the six tenets for ethical decision making in nursing
We all make ethical decisions every day. To walk or take public transportation. To buy organic or commercially raised food. To take an extra shift or attend a child’s performance. Over a lifetime, we learn how to consider and make choices among these types of situations where we weigh values, consider outcomes, and make choices with consequences. In life, ethics is about being a good person, thinking logically, and making reasoned choices. Ethics helps guide our behavior so that we can live civilly with other people in society.
As a registered nurse, one studies ethics because the everyday ethics we spend a lifetime developing often do not consider the kind of life-and-death decisions that nursing practice requires. Nurses often encounter competing interests/conflicts between their own beliefs, what the profession asks, what the patient wants and needs, what the institution requires, and what other health professionals demand. Studying nursing ethics and bioethics helps one develop tools to navigate the ethical labyrinth of the professional environment. Examining topics and issues that one is likely to encounter helps the nurse consider how she or he would act in a situation. Having considered varied cases, one has a better idea of how to act when confronted with a real-life dilemma.
In short, ethical nursing is good nursing. As a registered nurse you need to understand that ethics is the process of moral deliberation, of asking and reflecting on questions about how one ought to act or decide in a given situation. Ethics is an essential part of nursing that forms the backbone of how we treat our patients, our health care colleagues, our profession, and each other. You will need to understand Rest’s four components of moral competence that includes moral sensitivity, moral judgment, moral motivation, and moral character. Finally, it is important that you clearly understand six tenets of nursing ethics: virtue, caring, beneficence, nonmaleficence, and autonomy.
CASE SCENARIO
Jonathan Garcia has been a nurse for 8 years in labor and delivery. He is currently assisting Mrs. Jackson who is in labor with her third child, at 36 weeks gestation. She has placental previa and has refused to consent for blood transfusion if it should be necessary. On several occasions, Mrs. Jackson presented the team and her obstetrician with information from her church on why she rejects blood and blood products and has shared a copy of her blood refusal card. Dr. McComb is the physician on call and believes that Mrs. Jackson needs a C-section immediately. However, Dr. McComb declines to do surgery with the blood refusal in place.
“Don’t you want your baby to live?” Jonathan overhears Dr. McComb saying, “How would you feel if your baby doesn’t have a mother?” Mrs. Jackson is in tears and finally relents, “Enough. Please stop talking. Okay do the surgery. Save my baby.” During the C-section, Mrs. Jackson hemorrhages and Dr. McComb orders Jonathan to hang 4 units of blood.
Questions to Consider Before Reading On
1. What should Jonathan do?
2. How would the selected provisions/statements from the Code of Ethics (Box 1.1) be used to support Jonathan’s actions?
WHY STUDY ETHICS?
Cases like the one Jonathan faces where you have to make decisions without a clear “right” answer are one reason why nurses should study ethics. In ethics, one learns to be aware of sensitive issues and difficult situations. Studying ethics teaches one to form and ask questions, to reflect on the situation, and to consider potential resolutions.
Box 1.1
Ethical Terms, Theories, and Principles—Provisions and Relative Statements From the Code of Ethics
PROVISION 1
The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.
FROM INTERPRETIVE STATEMENT 1.4
Respect for human dignity requires the recognition of specific patient rights, in particular, the right to self-determination. Patients have the moral and legal right to determine what will be done with and to their own person; to be given accurate, complete, and understandable information in a manner that facilitates an informed decision; and to be assisted with weighing the benefits, burdens, and available options in their treatment, including the choice of no treatment. They also have the right to accept, refuse, or terminate treatment without deceit, undue influence, duress, coercion, or prejudice and to be given necessary support throughout the decision making and treatment process. . . .
Nurses have an obligation to be knowledgeable about the moral and legal rights of patients. Nurses preserve, protect, and support those rights by assessing the patient’s understanding of both the information presented and explaining the implications of decisions.
FROM INTERPRETIVE STATEMENT 2.1
The nurse’s primary commitment is to the recipients of nursing and health care services—patient or client—whether individuals, families, groups, communities, or populations. When the patient’s wishes are in conflict with others, nurses help resolve the conflict. Where conflict persists, the nurse’s commitment remains to the identified patient.
FROM INTERPRETIVE STATEMENT 2.2
Nurses must examine the conflicts arising between their own personal and professional values and the values and interests of others who are also responsible for patient care and health care decisions, and perhaps patients themselves. Nurses address these conflicts in ways that ensure patient safety and promote the patient’s best interests while preserving the professional integrity of the nurse and supporting interprofessional collaboration.
PROVISION 6
The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.
FROM INTERPRETIVE STATEMENT 6.1
Virtues are universal, learned, and habituated attributes of moral character that predispose persons to meet their moral obligations, that is, to do what is right.
There are more particular attributes of moral character, not expected of everyone, that are expected of nurses. These include knowledge, skill, wisdom, patience, compassion, honesty, altruism, and courage. These attributes describe what the nurse is to be as a morally “good nurse.”
FROM INTERPRETIVE STATEMENT 6.2
Obligations focus on what is right and wrong or what we are to do as moral agents.
Obligations are often specific in terms of principles such as beneficence or doing good; nonmaleficence or doing no harm; justice or treating people fairly; reparations, or making amends for harm; fidelity, and respect for persons.
FROM INTERPRETIVE STATEMENT 6.3
Nurses are responsible for contributing to a moral environment that demands respectful interactions among colleagues, mutual peer support, and open identification of difficult issues, which includes ongoing professional development of staff in ethical problem solving.
Source: ANA (2015).
WHAT IS ETHICS?
At some point in their careers, most nurses encounter scenarios like the one that Jonathan faces. These challenges may be over patient care, power differentials, differing goals of treatment, or perspective on the patient and family. In this section, we will examine the difference between ethics and morality.
Questions to Consider Before Reading On
1. How would you define ethics in your current nursing practice?
2. Provide an example of how you integrate ethics in everyday practice.
Most people have heard of the concept of ethics and at some point in life, everyone has had to make ethical decisions. Ethics is a part of everyday life. Pick up a newspaper and reports of ethics issues appear regularly: “Elected Official Guilty of Ethics Violation,” “CEO of Company X Dismissed on Ethics Charges,” “Doctor Reprimanded for Ethics Violations,” “News Agency Admits Ethics Violation in Reporting,” and “Nurses Struggle with Ethical Dilemmas.” Although each of these headlines uses the same word, the term ethics has a very different meaning in each situation.
In general, ethics is the “branch of knowledge dealing with moral principles” (“Ethics,” 2014). One of the earliest writers of ethics was the ancient Greek philosopher Aristotle who defined ethics as the application of moral knowledge. This definition is the philosophical one, meaning the examination of how people make decisions regarding what is right and what is wrong. As demonstrated in Table 1.1, the term “ethics” has different meanings in different contexts. When looking at the headlines about ethics in government or business, ethics refers to a branch of the legal code that deals with proper behavior. When an elected official commits an ethics violation, he or she is breaking the law. A business or government ethics violation can lead to fines or imprisonment.
The news agency, physician, and nursing headlines refer to when an organization or a profession develops a code of behavior that members of the profession are expected to follow: “The codes of conduct or moral principles recognized in a particular profession, sphere of activity, relationship, or other context or aspect of human life” (“Ethics,” 2014). Rather than being legal precepts, these are violations of agreed upon principles of behavior.
In the world of nursing, ethics is about what one ought to do (or ought not to do). The guide to ethical nursing conduct is the American Nurses Association’s Code of Ethics for Nurses (ANA, 2015). Thus, an ethical nurse is one who follows the principles of the Code. A second sense of ethics in nursing is making decisions about right and wrong. These situations are ambiguous and are not anticipated by either law or the Code. Ethics in this sense is a process of moral deliberation where one identifies the ethical issue, collects information, performs an analysis, and makes a well-informed and reflective decision.
Morality
As mentioned previously, ethics is a process of moral deliberation. This begs the question, What are morals and morality? Morality is a personal belief about what is right and what is wrong. Our morality is formed from our experiences. We learn it from our parents, our schools, religion, and popular media. Sometimes our morality is irrational and illogical. We might believe that abortion is wrong and capital punishment is acceptable even though both entail ending a potential human future.
Table 1.1
Definitions of Ethics
ETHICS | DISCIPLINE | DEFINITION |
Public Policy and Law | Following the legal code that dictates appropriate behavior | |
Business | Following the legal code that dictates appropriate behavior Moral principles that guide conduct | |
Philosophy | Examination of how people make decisions regarding right and wrong | |
Nursing | A professional code of conduct (ANA Code of Ethics) that guides nurses in what they ought to do in professional practice Making decisions about right and wrong in specific clinical situations |
Since morality is a belief, it does not have to be defended or explained. It is simply what you know to be true absent evidence. One’s morality is individual, even if you share beliefs with others, ultimately your version of right and wrong belongs to you.
Questions to Consider Before Reading On
1. Describe a care situation in which your morality or belief(s) influenced your action(s).
2. What was the outcome of the situation?
3. Did this outcome influence your beliefs and future actions? Why? Why not?
Bioethics
Bioethics is the subfield of philosophy that looks at ethical decision making and proper conduct in the life sciences: “The broad terrain of the moral problems of the life sciences, ordinarily taken to encompass medicine, biology, and some important aspects of the environmental, population and social sciences” (Reich, 1995, 250). This field evolved in the early 1970s and has become the umbrella term for ethics of the various health care professions. Nursing ethics is a subset of bioethics.
Bioethics brings together medical ethics, nursing ethics, public health ethics, and other professionally based ethics into a single subfield as a result of four social forces. The first reason for the rise of bioethics was the rapid advance in life science and health care delivery technology since the mid-20th century. Kidney transplants, chronic dialysis, liver transplants, heart transplants, and in vitro fertilization all changed the way that health care professionals related to the human body and the possibilities for medical healing.
Second, bioethics arises from media reports on abuses in human research. A 1972 article in The New York Times by journalist Jean Heller introduced the public to the “Tuskegee Study of Untreated Syphilis in the Negro Male.” This was a research program from 1932 to 1972 in which nearly 600 African American men were observed as part of a study in the natural progression of syphilis. Even though a cure for syphilis became widely available in the 1940s, the subjects were actively isolated from access to cure. A second article was a publication by Harvard anesthesiologist Henry Beecher in The New England Journal of Medicine where he outlined 22 human research studies that he felt violated ethical standards.
The third social force was engagement with the public. Physicians, nurses, lawyers, theologians, philosophers, and other scholars interested in ethical issues in the life sciences were sought by the media to comment on advances in medical technology. The U.S. government also engaged those active in these issues by recruiting scholars to serve on panels to investigate the social implications of human subjects in research and medical advances in order to guide the development of law, policy, and regulation.
Fourth, bioethics evolves out of the Civil Rights movement. Prior to the 1970s, physicians, and to a lesser extent nurses, made most patient medical decisions. During the late 1960s/early 1970s, people who had limited political voice were demanding their equal rights in the public sphere. Similarly, patients demanded the right to make their own decisions in the health care sphere. Patients and their families wanted to know the diagnosis and prognosis of disease. Rather than being a subject of health care, they wanted to be partners with health care professionals in deciding treatment and future care.
BRIEF HISTORY OF NURSING ETHICS
Since its founding, ethics has been an integral part of the nursing profession. Florence Nightingale, the recognized founder of modern nursing, was particularly concerned with the ethical conduct of her nurses. In her writings from the late 1800s, she explained that a nurse was focused foremost on the patient’s recovery and comfort. The nurse is diligent, observant, concise, confident, quiet and knows her role in the health care and household hierarchy (Nightingale, 2010). These values provide guidance for behavior and action in nursing.
Mrs. Lystra E. Gretter wrote the Florence Nightingale Pledge in 1893. Gretter, who was at the Farrand Training School for Nurses in Detroit, modified the Hippocratic Oath that was followed mainly by physicians. Her pledge focuses primarily on the nurse’s character, profession, confidentiality, and relationship to the physician:
I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping and family affairs coming to my knowledge in the practice of my calling. With loyalty, will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care (Gretter, 1893).
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