Ethics and Deontology in Nursing

William James, famous American psychologist and philosopher (1842-1910), wrote: "A great many people think they are thinking when they are merely rearranging their prejudices." This is important because we walk into all situations with our own private baggage: values, beliefs, cultural heritage, prejudices, etc. It is important in ethical issues to realize that the other people involved have brought their baggage as well. Nurses need to be aware of their own prejudices, values and viewpoints and alert to signals others give them in order to even begin to understand a given situation.

Definition Ethics is a systematic study of what you ought to do in a given situation. An ethical system is a system of moral standards and values that guide right and wrong. These are standards that govern human conduct. Ethics do not give clear cut answers, only guidelines of possible behavior.

Throughout time philosophers have wrangled with the concepts of human behavior. There are two basic schools of thought in theories of ethics. One is idealism, first proposed by Plato (427?-347? B.C.). Idealism is the belief that truth can be known by reasoning alone. This is the type of thinking done by Rene Descartes (1596-1650) who spent his life trying to prove or disprove the existence of God. In the end he said that all he could really prove was that he existed, and his existence could only be proven by the fact that he was capable of thought. His most widely known statement was: "I think, therefore I am." This supports the query: if a tree falls in the forest and there is no one there to hear it, does it make a noise?

Realism is the opposite of idealism and is attributed to Aristotle (384-322 B.C.). Realism is the doctrine that material objects exist in themselves, apart from the mind's consciousness of them. To Aristotle, if the tree falls it makes a noise, period. No one needs to be there to hear it. Sartre's and Camus' Existentialism falls under the general heading of realism. These philosophers would say: "I am, therefore I think."

Definition of Terms Justice - Justice is fairness to everyone, sound reason, rightfulness of decisions and actions. Rights - Rights are the belief that everyone has certain inalienable rights simply by being human. Formalism - Formalism is strict adherence to customs such as religious tenets, no swaying from the straight and narrow path. Beneficence - Beneficence is the duty to do good, not harm to others.

Definition of Terms Nonmaleficence - Nonmaleficence is the duty to do no harm to others. Freedom - Freedom is the belief that everyone is entitled to make choices and holds that the person is responsible for the consequences of their actions. Fidelity - Fidelity is the duty to be true and loyal to others. Deontology - Deontology is the belief that an act is either good or bad based upon the act itself, regardless of the consequences of that act.

Definition of Terms Existentialism - Existentialism is the doctrine that existence takes precedence over essence and holds that man is totally free to make choices and is responsible for the consequences of his actions. Individualism - Individualism is the doctrine that the individual is paramount, that things exist for the individual not the other way around, that self-interest is the proper goal of all human actions. Humanism - Humanism is the belief that the human being is the supreme being. Humans are capable of self-fulfillment, ethical conduct, etc, without recourse to the supernatural. Utilitarianism - Utilitarianism is the belief that an act is either right or wrong based on the consequences of the act. This is also the doctrine of the greatest good for the greatest number of people. With this theory, a person's value in society would be based on his or her utility within that society.

Definition of Terms Teleology - Teleology is the study of final causes, the belief that things occur for a reason, a design of nature. A teleologist would look at a utilitarian answer to see if the end justified the means. This is also the basis of religious tenets. Determinism - Determinism is the doctrine that everything that happens is determined by a sequence of causes independent of oneself. The religious belief in predestination, that your days are numbered, comes from this theory. Emotivism - Emotivism is the belief that emotions are the basis of individual reality. Intuitivism - Intuitivism is the doctrine that all things are understood in their real nature through intuition. The rightness or wrongness of acts or fundamental moral principles are understood intuitively. Intuitionists believe that intuition is really logical thought done very rapidly.

Definition of bioethics Bioethics is the study of ethics that result from technological scientific advances in the areas of biology and medicine. These are issues which arise simply because we are now able to do more with people and research than we could in the past. The ethical principles and theories are the same as those described above.

Code for Nurses The American Nurse's Association has developed a Code for Nurses. This document is sometimes referred to as the Ethical Code for Nurses. The Code was first written in 1950 and has undergone periodic revisions since then. All nurses are held to the Code, so it is a good idea to own one and read it. It's always nice to know the standards to which you are legally bound.

The Code gives common ethical principles and guidelines for nurses such as our responsibilities to clients, to our profession and to our colleagues. It also informs society about the professional requirements in nursing for ethical concerns.

An ethical dilemma is the choice between two or more equally justifiable alternatives. Aiken (1994) presented the following model:

Collect, analyze and interpret the data State the dilemma, make a clear statement of the situation Consider the choices of action, all options open to the client Analyze the advantages and disadvantages of each course of action Make the decision NB! The final decision may not be one that meets all or even most of the concerns of the nurse. It is based on the best choices at a given point in time for that client and the client's family.

Tests

Scott is ventilator dependent Scott is ventilator dependent. He suffered a total transection of his spine at C4. He is only 17. Scott pleads with his care givers to be taken off the ventilator. "I have the right to refuse treatment! I do not want to live trapped in this body!" Does he have the right to refuse treatment even though he isn't terminally ill or imminently dying? How would you feel in this situation? Make a concise statement of the problem. What ethical principles would guide you in this case? How would you rank order these ethical principles? What alternatives are there for resolving this dilemma? What are the possible consequences for each of the alternatives that are consistent with your values? (Remember to consider the physical, psychological, social, spiritual, short-term and long term consequences) How would you prioritize the alternatives? What is your plan of action?

Marilyn is suffering from inoperable cancer Marilyn is suffering from inoperable cancer. When alert, her pain is so intense she cries and draws herself into a fetal position. Her family is distraught. The doctor has ordered continuous intravenous morphine sulfate at an accepted rate. Her family wants you to increase the rate so that Marilyn is kept under and completely oblivious to her condition. How would you feel in this situation? Make a concise statement of the problem. What ethical principles would guide you in this case? How would you rank order these ethical principles? What alternatives are there for resolving this dilemma? What are the possible consequences for each of the alternatives that are consistent with your values? (Remember to consider the physical, psychological, social, spiritual, short-term and long term consequences) How would you prioritize the alternatives? What is your plan of action?

Jason is 71 and adamant about not being resuscitated Jason is 71 and adamant about not being resuscitated. "When my time comes, let it come! His wife tells all of you that she wants "everything done for my husband." There have been team conferences and sensitive counseling. Still each of them is firm and the nurses are concerned over what is right to do if Jason has a cardiopulmonary arrest. His doctor refuses to write a "do not resuscitate" order. How would you feel in this situation? Make a concise statement of the problem. What ethical principles would guide you in this case? How would you rank order these ethical principles? What alternatives are there for resolving this dilemma? What are the possible consequences for each of the alternatives that are consistent with your values? (Remember to consider the physical, psychological, social, spiritual, short-term and long term consequences) How would you prioritize the alternatives? What is your plan of action?

Colleen's cancer is out of control Colleen's cancer is out of control. "There's nothing more we can do," she was gently told. She wants her doctor to start total parenteral nutrition (TPN) by intravenous route so she can try "one more round of the research protocol of medication and make it to my son's graduation. "Her son is five and is in kindergarten. Her doctor agrees the TPN will offer her nutritional support and energy, but the side effects of the treatment are unduly burdensome and could cost her life. Should the treatment be started because she wants it though the doctor disagrees? How would you feel in this situation? Make a concise statement of the problem. What ethical principles would guide you in this case? How would you rank order these ethical principles? What alternatives are there for resolving this dilemma? What are the possible consequences for each of the alternatives that are consistent with your values? (Remember to consider the physical, psychological, social, spiritual, short-term and long term consequences) How would you prioritize the alternatives? What is your plan of action?

Sarah is 11 years old with leukemia and has been admitted to the hospital 17 times. This time it's for a bone marrow transplant. She wants no more treatment. Her parents don't know what is best anymore. How would you feel in this situation? Make a concise statement of the problem. What ethical principles would guide you in this case? How would you rank order these ethical principles? What alternatives are there for resolving this dilemma? What are the possible consequences for each of the alternatives that are consistent with your values? (Remember to consider the physical, psychological, social, spiritual, short-term and long term consequences) How would you prioritize the alternatives? What is your plan of action?

Angela is 96 years old. Both her hands and feet are severely handicapped with rheumatoid arthritis. She is admitted to the hospital with a bowel obstruction and severe rectal hemorrhage. She is confused and is babbling incoherently. Her daughter wants her mother to have immediate surgery and other aggressive treatments. Her granddaughter says she has spoken often with Angela about death. She says her grandmother just wants to die peacefully. There is no living will. How would you feel in this situation? Make a concise statement of the problem. What ethical principles would guide you in this case? How would you rank order these ethical principles? What alternatives are there for resolving this dilemma? What are the possible consequences for each of the alternatives that are consistent with your values? (Remember to consider the physical, psychological, social, spiritual, short-term and long term consequences) How would you prioritize the alternatives? What is your plan of action?

Thank you for attention!