1. Chapter 9 Ethical and Bioethical Issues in Nursing and Health Care Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

2.  Definition: system of principles that govern the actions of the nurse in relation to patients, families, other health care providers, policymakers, and society Nursing Ethics 2 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

3.  Code of ethics  Implicit standards and values for the profession  American Nurses Association Code of Ethics  International Council of Nurses Code for Nurses Nursing Ethics (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 3

4.  Description  Interdisciplinary field within health care that has evolved with modern medicine to address questions that arise as science and technology produce new ways of knowing  Physicians, nurses, social workers, psychiatrists, clergy, philosophers, and theologians are joining to address ethical questions in health care Bioethics Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 4

5.  Dilemmas for health professionals  Life and death  Quality of life  Right to decide  Informed consent  Alternative treatment issues  Stem cell research  Therapeutic and reproductive cloning  In vitro fertilization; donor insemination  Surrogate motherhood  Organ transplantation Bioethics (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 5

6.  Dilemmas created by technology  Illnesses that once led to mortality are now manageable and are classified as chronic illnesses  Cost is a consequence of prolonging life with technology  Manipulation of DNA Bioethics (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 6

7.  Answering difficult questions  What is safe care?  When staffing is inadequate, what care should be accepted or refused?  What does it mean to be ill or well?  What is the proper balance between science/technology and the good of humans?  Where do we find balance when science will allow us to experiment with the basic origins of life? Ethical Decision Making Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 7

8.  Balancing science and morality  Nurses must examine life and its origins, as well as its worth, usefulness, and importance  Nurses must determine their own values and seek to understand the values of others Ethical Decision Making (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 8

9.  Health care decisions  Decisions are made with the patient, family, other nurses, and other health care providers  Nurses must develop a reasoned thought process and sound judgment in all situations that take place within the nurse-patient relationship Ethical Decision Making (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 9

10.  Definitions  Value: personal belief about worth that acts as a guide to behavior  Value system: entire framework on which actions are based  Values clarification: a process by which people attempt to examine the values they hold and how those values function as a part of the whole  Moral development: forming a worldview and value system through an evolving, continuous, dynamic process that moves along a continuum of development Values Formation and Moral Development Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 10

11.  Examining value systems  Nurses must examine their own value systems; values clarification Diane Ustal: first nurse leader to describe the role of values clarification  Ethics acculturation  Nurses must commit to a virtuous value system  Worldview Provides a cohesive model for life Encourages personal responsibility for living life Prepares one for making ethical choices Values Formation and Moral Development (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 11

12.  Learning right and wrong Infants  Begin with no concept of right or wrong  If the need for basic trust is met, infants will develop the foundation for secure moral thought School-age children  Learn that good behavior is rewarded and bad behavior is punished  Begin to make choices that are based on an understanding of good and bad Values Formation and Moral Development (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 12

13. Adolescent  Questions existing moral values and his or her relevance to society  Becomes more aware of contradictions in adults’ value systems Adult  Strives to make sense of the contradictions and learns to develop own set of morals and values  Begins to make choices that are based on an internalized set of principles Values Formation and Moral Development (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 13

14.  Understanding moral development theory Kohlberg’s theory: most widely accepted; a cognitive developmental process that is sequential in nature  Rules imposed by authority  Conformity to expected social and religious mores  Autonomous thinker who strives for a moral code beyond the issues of authority and reverence Values Formation and Moral Development (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 14

15. 1.Wong (Hockenberry et al, 2007) describes learning right from wrong as being based on developmental stages. At what developmental stage is a human first able to integrate values of significant others into his or her behavioral system? A.Infant B.Toddler C.School-age child D.Adolescent Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 15

16.  Moving toward moral maturity Quality of complex health care decisions depends on the level of moral development of the professionals entrusted with decision making Values essential for the professional nurse  Altruism: concern for the welfare of others  Autonomy: right to self-determination  Human dignity: respect for inherent worth and uniqueness of individuals and populations  Social justice: acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability, or sexual orientation Values Formation and Moral Development (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 16

17.  Ethics acculturation  Integrity, personal growth, practical wisdom, and effective problem solving  Rights of conscience  Ethical theory and ethical principles can provide a basis for moving forward as a morally mature professional adult Moving Toward Moral Maturity Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 17

18. 2.A homeless person comes to the emergency department after being beaten. The nurse asks permission to remove the tattered clothing and carefully folds and places the clothing to prevent further soiling. The nurse informs the legal system that this person was assaulted and assists with securing legal representation. The nurse is at which moral development stage? A.Unconventional B.Preconventional C.Conventional D.Postconventional Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 18

19.  Definition: a system of principles by which a person can determine what ought and ought not to be done Ethical Theory Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 19

20.  Utilitarianism  Rooted in the assumption that an action or practice is right if it leads to the greatest possible balance of good consequences, or to the fewest possible bad consequences  Strongest approach for bioethical decision making— Which action will lead to the greatest ratio of benefit to harm for all persons involved? Ethical Theory (cont'd) 20 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

21.  Deontology  Rooted in the assumption that humans are rational and act out of principles that are consistent and objective, and compel them to do what is right  A decision is right only if it conforms to an overriding moral duty and wrong only if it violates that moral duty  All decisions are made in such a way that the decision could become universal law Ethical Theory (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 21

22.  Purpose of ethical principles  Establish common ground among nurse, patient, family, other health care professionals, and society for discussion of ethical questions and ethical decision making  Permit people to take a consistent position on specific or related issues  Provide an analytical framework by which moral problems can be evaluated Ethical Principles Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 22

23.  Autonomy  Principle of respect for the person: primary moral principle  Unconditional intrinsic value for all persons  People are free to form their own judgments and actions as long as they do not infringe on the autonomous actions of others  Concepts of freedom and informed consent are grounded in this principle Ethical Principles (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 23

24.  Beneficence  To promote goodness, kindness, and charity  To abstain from injuring others and to help others further their own well-being by removing harm; risks of harm must be weighed against possible benefits  Common bioethical conflict results from an imbalance between the demands of beneficence and those of the health care delivery system Ethical Principles (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 24

25.  Nonmaleficence  Implies a duty not to inflict harm  To abstain from injuring others  To help others further their own well-being by removing harm Ethical Principles (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 25

26.  Veracity  Principle of truth-telling  Belief that truth could at times could be harmful held for many years  Consumers expect accurate and precise information revealed in an honest and respectful manner  To develop trust between providers and patients, truthful interaction and meaningful communication must occur  Challenge is to mesh need for truthful communication with the need to protect Ethical Principles (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 26

27.  Situation assessment procedure  Identify the ethical issues and problems What is the issue? What are the hidden issues? What are the complexities of the situation? Is anything being overlooked? Ethical Decision-Making Model Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 27

28.  Identify and analyze available alternatives for action What are the reasonable possibilities for action? How do the affected parties want to resolve the problem? What ethical principles are required for each alternative? What assumptions are required for each alternative and what are their implications for future action? What additional ethical problems are raised by the alternatives? Ethical Decision-Making Model (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 28

29.  Select one alternative Integration of multiple factors A reasonable and purposeful decision results from the blending of ethical theory, principles, and values 29 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Ethical Decision-Making Model (cont'd)

30.  Justify the selection Decision maker must be prepared to communicate his or her thoughts through an explanation or the reasoning process used Justification process  Specify the reasons for the action  Clearly present the ethical basis for these reasons  Understand the shortcomings of the justification  Anticipate objections to the justification 30 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Ethical Decision-Making Model (cont'd)

31.  Usefulness and application of the situation assessment procedure  Certain ethical issues will be resolved within the context of the patient-provider relationship  Other ethical issues that may be more encompassing are addressed in group settings Institutional ethics committees are common within heath care organizations Purposes of the committee are to provide ethics education and assistance with ethical policy development, and to serve as a consultative body in helping to resolve ethical dilemmas 31 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Ethical Decision-Making Model (cont'd)

32.  Applicable to the daily practice level of ethical decision making  Applicable to the policymaking level, where professionals come together to consider right and wrong choices that affect society as a whole 32 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Ethical Decision-Making Model (cont'd)

33.  Definition  Dilemmas that pose a choice between perplexing alternatives in the delivery of health care because of the lack of a clear sense of right or wrong  Nurses should consider the dilemmas that might arise in a given practice setting Bioethical Dilemmas: Life, Death, and Dilemmas in Between Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 33

34.  Life  Bioethical abortion issue When does life begin? Nurses serving in women’s and children’s health settings must be prepared to face this morally laden issue  Reproduction issue: influenced by genetic screening, genetic engineering, and cloning Bioethical Dilemmas: Life, Death, and Dilemmas in Between (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 34

35.  Death  Quality of life and definition of death issues: With advances in health care, what is usual and what is heroic care has become unclear  Euthanasia and assisted suicide present new ethical questions  Nurses in every setting must be prepared to consider end-of-life questions Bioethical Dilemmas: Life, Death, and Dilemmas in Between (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 35

36.  Dilemmas in between  Right to health care Health care system more selective in the amount and type of treatment offered as a result of managed care Is each person entitled to the same health care package? Does ability to pay affect specific level of entitlement? How ethical is gatekeeping in the new managed care system? Access to health care and respect for human dignity are at the core of nursing practice Bioethical Dilemmas: Life, Death, and Dilemmas in Between (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 36

37.  Allocation of scarce resources Should the recipient of scarce resources be selected on the basis of quality of life? Ability to pay? Best prognosis? First- come, first-served? Nurses should be prepared to consider questions regarding allocation of scarce resources Bioethical Dilemmas: Life, Death, and Dilemmas in Between (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 37

38.  The challenge of veracity  Issues of alternative treatments and acknowledgment of uncertainty test truth-telling  Which treatment among two or more is best for the patient?  Which of the new drugs should be used?  Should every patient be subjected to every possible form of diagnostic treatment?  Should patient be made aware of questions and various options surrounding care?  Is disclosure of uncertainty beneficial or detrimental? Ethical Challenges Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 38

39.  The challenge of paternalism  Provider tries to act on behalf of the patient and believes that his or her actions are justified because of a commitment to act in the best interest of the patient  Interferes with a patient’s right to self-determination Ethical Challenges (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 39

40.  The challenge of autonomy  Makes way for the crucial legal step of informed consent  When are patients competent to make informed consent decisions? Can family members or surrogates make decisions by proxy?  Questions about informed consent are raised for minors, confused older adults, mentally compromised, imprisoned, inebriated, unconscious, and those in emergency situations  Nurses also must take responsibility for understanding and educating people about advance directives Ethical Challenges (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 40

41.  The challenge of accountability  Nurses have an obligation to uphold the highest standards of practice, to assume full and professional responsibility for every action, and to commit to maintaining quality in the skills and knowledge base of the profession  Obligation to denounce a harmful action or potentially threatening situation may fall to a fellow member of the profession; to remain silent is to consent to the action of the threatening situation Ethical Challenges (cont'd) Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 41