Ethics in Nursing

Ethics

systematic inquiry into the principles of right or wrong conduct, of virtue or vice, and of good and evil
as they relate to conduct

a. morals, although similar in meaning to ethics, usually refer to personal standards of right and
wrong in conduct, character, or attitude

ethical conduct essential to the practice of professional nursing

a. described in the nursing code of ethics

i. formal statement that determines the standards of conduct of a professional nurse

b. the nursing code of ethics reflects the following underlying moral principles:

i. autonomy (the right to make one’s own decisions)

ii. nonmaleficence (duty to do no harm)

iii. beneficence (doing good)

iv. justice (fairness)

v. fidelity (faithfulness to agreements and responsibilities one has undertaken)

vi. veracity (telling the truth)

functions of the nursing code of ethics

i. inform the public about the minimum standards of the profession and to help them
understand professional nursing conduct

ii. to provide a sign of the profession’s commitment to the public it serves

iii. to outline the major ethical considerations of the profession

iv. to provide general guidelines for professional behavior

v. to guide the profession in self-regulation

vi. to remind nurses of the special responsibility they assume when caring for the sick

ethical theories and frameworks

a. teleology

i. teleology views the rightness or wrongness of an action as being dependent upon the
consequences the action produces

a. emphasizes happiness, pleasure, and absence of pain

 ii. e.g., Utilitarianism:

a. emphasizes the utility or inutility of an action, or its instrumental value

b. utile act:

1.brings the greatest amount of good into existence for the greatest number of
people

2. thus the end justifies the means utilized to obtain it

c. inutile act

i. produces harmful effects

d. Utilitarianism applied to euthanasia:

i. "euthanasia, which ends unbearable suffering, is not murder, and morally right"

b. deontology

1. deontology views an action as right or wrong independent of the consequences it

produces

a. emphasizes duty, rationality, and obedience to rules

ii. e.g., Kantian theory:

a. emphasizes that respect for persons is the primary test of one's duties with three
components to this imperative:

i. that all persons must be respected as persons

ii. that all persons must respect their own humanity

a. e.g., people on suicidal missions, such as Kamikaze pilots, do not respect their
own humanity

iii. that all persons must never be treated as the means to an end

a. e.g., prostitutes should not use "Johns" as the means to an end, such as to
make money, and "Johns" should not use

prostitutes as a means to and, such as only to satisfy sexual desires

2.. Kantian theory applied to euthanasia:

i. "euthanasia, even if it ends unbearable suffering, is murder, and morally wrong"

c. institutionism

i. the notion that people inherently know what is right or wrong

ii. as such, right or wrong actions do not need to be taught

 d. caring

i. based on relationships

ii. emphasizes courage, generosity, commitment, and responsibility

iii. force for protecting and enhancing patient dignity

iv. uses touch and truth-telling to affirm patients as persons rather than objects and to assist
them to make choices and find meaning in their illness

types of ethical problems

1. decision-focused ethical problems

i. difficulty lies in what to do

ii. typically, two or more moral principles can apply

iii. results in a moral dilemma

iv. can be resolved by improving one’s decision-making skills

v. to deal successfully with these problems, the nurse must shift attention to "making the
right decision" by improving his/her decision-making skills

2. action-focused ethical problems

i. difficulty lies not in what to do, but in implementing it

ii. typically, the nurse feels secure in the decision about what is right, but to act on his/her
decision puts him/her at personal risk

iii. results in moral distress

iv. cannot be resolved by improving one’s decision-making skills

v. to deal successfully with these problems, the nurse must shift attention from "making the
right decision" and focus on factors that are preventing the

"right action"

steps to resolve ethical problems by use of a decision-making model

a. identify the moral aspects of nursing care

b. gather relevant facts related to the case

c. determine ownership of the decision

d. clarify and apply personal values

e. identify ethical theories and principles

f. identify applicable laws or agency policies

 g. utilize competent interdisciplinary resources

h. develop alternative actions and project their outcomes on the patient and family

i. apply the nursing code of ethics to help guide actions

j. for each alternative action, identify the risk and seriousness of consequences for the nurse

k. participate actively in resolving the issue

l. implement the action

m. evaluate the action taken

common ethical problems faced by nurses

1. between nurses and patients

i. paternalism

a. e.g., a nurse decides to obtain an order to restrain an elderly patient who is at risk for
falling because she believes it to be in the patient's best

interest even though the patient does not feel the same way

ii. deception

a. e.g., a student nurse does not tell a patient that this is his first injection in order to
decrease the patient's anxiety

iii. confidentiality

a. e.g., a patient tells you in confidence that she doesn't know how she will pay for the
hospital bill because she is an illegal alien

i. ANA statement "the nurse safeguards the patient's right to privacy by judiciously
protecting information of a confidential manner"

iv. allocation of scarce nursing resources

a. e.g., a nurse working in labor and delivery has two mothers in active labor who are fully
dilated and ready to be moved into the delivery room at

the same time

v. informed consent

a. e.g., an intern wants a nurse to assist him while he "practices" inserting a central venous
pressure (CVP) line in a patient who has just died to

get experience in the procedure

vi. conflicts between the patients' and nurses' interests

 a. e.g., a nurse refuses to take care of a HIV-positive patient because she is afraid of passing
on the virus to her infant whom she is nursing

i. ANA statement, "the moral obligation to care for a HIV-positive patient cannot be set
aside unless the risk exceeds the responsibility"

b. e.g., a nurse refuses to care for a patient who is to have an abortion because of her
Catholic faith

i. conscience clauses permit individual physicians, nurses, and institutions to refuse to

assist with an abortion if doing so violates their

religious or moral principles

2. between nurses and physicians

i. disagreements about the proposed medical regimen

a. e.g., a physician orders a nurse to insert a feeding tube and start tube feedings in a
patient; a nurse disagrees because the patient has made

it clear to both the physician and the nurse her opposition to the procedure

i. ANA statement, "it is morally as well as legally permissible for nurses to honor the
refusal of food and fluids by competent patients in

their care"

ii. conflicts regarding the scope of the nurse's role

a. e.g., a nurse, who assesses that a patient's bladder is distended, calls the patient's
physician with this information to which he responds, "a

nurse wouldn't know how to assess a distended from an undistended bladder"

iii. physician incompetence

a. e.g., a nurse notices that a particular general surgeon's patients seem to have a higher
than to be expected rate of surgical wound infections

3. between nurses and nurses

i. claims of loyalty

a. e.g., a nurse forgets to give a patient his antibiotic and, when the nurse on the following
shift her tells her of this fact, the first nurse signs the

medication administration record as if she gave the antibiotic and tells the other nurse
not to report her action

ii. nurse incompetence

a. e.g., a nurse and patient smell alcohol on the breath of another nurse on the unit
advocacy

a. protecting and supporting of another's rights by pleading the case of another

b. patient advocate

i. an individual who protects and supports the rights of a patient by pleading the case of the
patient

c. actions of patient advocates

i. informing patients

a. about their rights in a situation and providing them with the information they need to
make an informed decision, e.g.:

i. determining if the patient agrees to receiving the information

ii. either having the necessary information or knowing how to get it

iii. wanting the patient to have the information

iv. presenting the information in a way that is meaningful to the patient

v. dealing with the fact that there are those who do not wish the patient to be
informed

ii. supporting patients

a. in their decisions in an objective manner that conveys neither approval or disapproval,

even if the nurse believes it is wrong

ethics committees
a. review cases ensuring that relevant facts are brought out

b. write guidelines and policies

c. provide education and counseling

d. provide a forum in which diverse views can be expressed

e. reduce stress for caregivers

f. reduce legal risks

Values
freely chosen, enduring attitudes or beliefs about the worth of a person, object, idea, or action

a. attitudes

1. feeling or an emotion, generally including a positive or negative judgment, toward a

person, object, idea, or action

three components of an attitude

1. affective component

the feeling associated with an attitude

2. cognitive component

the factual information associated with an attitude

3. behavioral component

i. the inclination to act in a certain way associated with an attitude

Beliefs
a special class of attitudes based primarily on faith as opposed to fact

Value system
the organization of a person's values in which each value is ranked along a continuum of relative
importance which operates as a personal code of ethics

types of values
a. religious (obtains strength from religious beliefs)

b. theoretical (holds truth, rationality, and empiricism in high esteem)

c. political (values power)

d. economic (values usefulness and practicality)

e. aesthetic (values beauty, harmony, and form)

f. social (values human interactions, is kind, sympathetic, and unselfish)

transmission of values
1. modeling

children learn what is of high or low value by observing parents, peers, and significant others.
Thus, modeling may lead to socially acceptable or

unacceptable behavior
 2.moralizing

children are taught a complete value system by parents or an institution (e.g., church or
school) that allows little opportunity for children to weigh

different values

3.Laissez-faire

children are left to explore values (no one set of values is presented as best for all) and to
develop a personal value system. This approach is often

accompanied by little or no guidance and can lead to confusion or conflict

4. rewarding and punishing

children are rewarded when demonstrating values held by parents and punished when
demonstrating unacceptable values

5.responsible choice

children are encouraged to explore different values and to weigh their consequences.
Support and guidance are offered as children develop a personal

value system

values essential to the practice of professional nursing (ANA, 1976)

aesthetics (qualities of objects, events, and people that provide satisfaction)

1. attitudes and personal qualities that demonstrate aesthetics

a. appreciation, creativity, imagination, sensitivity

2.example of a professional nursing behavior that demonstrates aesthetics

a. adapting the environment so that it is pleasing to the patient

altruism (concern for the welfare of others)

1.attitudes and personal qualities that demonstrate altruism

a. caring, commitment, compassion, generosity, perseverance

2.example of a professional nursing behavior that demonstrates altruism

a. assisting other personnel in providing care when they are unable to do so

3. equality (having the same rights, privileges, or status)

1. attitudes and personal qualities that demonstrate equality

a. acceptance, assertiveness, fairness, self-esteem, tolerance

2.example of a professional nursing behavior that demonstrates equality

 a. providing nursing care based on the individual patient's needs irrespective of his/her
personal characteristics

4. freedom (capacity to exercise choice)

1. attitudes and personal qualities that demonstrate freedom

a. confidence, hope, independence, openness, self-direction, self-discipline

2. example of a professional nursing behavior that demonstrates freedom

a. honoring an individual patient's right to refuse treatment

5. human dignity (inherent worth and uniqueness of an individual)

1. attitudes and personal qualities that demonstrate human dignity

a. consideration, empathy, humanness, kindness, respectfulness, trust

2. example of a professional nursing behavior that demonstrates human dignity

a. safeguards the patient's right to privacy

6.justice (upholding of moral and legal principles)

i. attitudes and personal qualities that demonstrate justice

a. courage, integrity, morality, objectivity

ii. example of a professional nursing behavior that demonstrates justice

a. allocates nursing care fairly

7.truth (faithfulness to fact and reality)

1. attitudes and personal qualities that demonstrate truth

a. accountability, authenticity, honesty, inquisitiveness, rationality, reflectiveness

2. example of a professional nursing behavior that demonstrates truth

a. documenting nursing care accurately and honestly

value neutrality as essential to the practice of professional nursing

a. a nurse should strive to be aware of his/her own and a patient's values and not assume that
his/her own values are superior to those of a patient

VII. clarification of values

a. a process by which people, including both nurses and patients, identify, examine, and develop
their own individual values and value system

b. includes cognitive, affective, behavioral components

1. cognitive component (choosing)

 a. freely, without outside pressure

b. from among alternatives

c. after reflecting and considering consequences

2. affective component (prizing)

a. chosen beliefs are prized and cherished

3. behavioral component (acting)

a. affirmed to others

b. incorporated into one's behavior

c. repeated consistently in one's life