Ethical Concerns in Nursing
Practice
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Values, Morals, & Ethics
• Values: are freely chosen,
enduring beliefs or attitudes
about the worth of a person,
object, idea, or action (e.g.
freedom, family, honesty, hard
work)
• Values frequently derive from a
person’s cultural, ethnic, and
religious background; from
societal traditions; and from the
values held by peer group and
family
• Values form a basic for
Behaviour “purposive
Behaviour”; The purposive
behavior is based on a person’s
decisions/choices, and these
decisions/choices are based on
the person’s underlying values.
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• Values are learned and are greatly
influenced by a person’s
sociocultural environment (e.g.
demonstrate honesty, folk healer,
observation and experience)
• People need societal values to feel
accepted, and they need personal
values to produce a sense of
individuality.
• Professional values often reflect and
expand on personal values
• Once a person becomes aware of
his/her values, they become an
internal control for behavior, thus, a
person’s real values are manifested
in consistent pattern of behavior
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• Nurses acquire these values
during socialization into nursing –
from codes of ethics, nursing
experiences, teachers, and peers.
• Watson (1981) outlined 4
important values of nursing:
• Strong commitment to service
• Belief in the dignity and worth
of each person
• Commitment to education
• Autonomy
• nurses often need to behave in a
value-natural way (i.e. being
nonjudgmental)
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• Nurses need to understand their own
values related to moral matters and
to use ethical reasoning to determine
and explain their moral positions.
• Moral principles are also important,
otherwise, they may give emotional
responses which often are not
helpful.
• Although nurses can not and should
not ignore or deny their own and the
profession’s values, they need to be
able to accept a client’s values and
beliefs rather than assume their own
are the “right ones”
This acceptance and nonjudgmental
approach requires nurses to be
aware of their own values and how
they influence behavior
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• What values you hold about life,
health, illness, and death.
• How do your values influence the
nursing care you provide?
• We should explore our own values
and beliefs regarding such situations
as the following:
• An individual’s right to make
decisions for self when conflicting
with medical advice
• Abortion
• End-of –life issues
• Cloning
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• The process of
becoming more
conscious of and
naming what one values
or considers worthy is
known as “value
clarification”
• In value clarification:
we examine what we
believe is good, bad,
beautiful, worthy,
meaningful, …..and
explore the process of
determining our
personal values.
Why?
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Facts vs. Values:
• Factual Statement:
scientists often perform
painful experiments on
animals.
• Value Statement: it is
morally acceptable (morally
required, morally wrong) for
us to perform painful
experiments on animals.
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• Factual Statement: We
created and used the
atomic bomb.
• Value Statement:
Creating and using the
atomic bomb was morally
right (morally wrong).
• Factual statement:
someday we will have
the technology to clone
human beings.
• Value statement: It is
morally acceptable
(unacceptable) to clone
human beings
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• Factual Statement: scientists often perform painful
experiments on animals.
• Value Statement: it is morally acceptable (morally required,
morally wrong) for us to perform painful experiments on
animals.
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The purposes of value clarifications
 This increase our self-awareness or understanding of
ourselves and assist us in making choices.
 It facilitates decision-making, because we have a
better grasp of our own value system.
 Consequently, this will be helpful when you are faced
with an ethical dilemma
• Ethical dilemma occurs when an individual must
choose between two unfavorable alternatives “e.g.
assisted suicide”
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• Ethical dilemma usually have
no perfect solution and those
making decisions may find
themselves in the position of
having to defend their decisions
• Value conflict occurs when we
must choose between two
things, both of which are
important to us.
• It’s the nurses’ role to help
clients identify values and
clarify them……
But
How??????
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Helping clients identifying their
values
•
List alternatives
•
Examine possible consequences of choices
•
Choose freely
•
Feel good about the choice
•
Affirm the choice
•
Act on the choice
•
Act with a pattern
Remember: never impose your personal values
never offer an opinion
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Morals and Ethics
• Morals: is similar to ethics and
many people use the two
wards interchangeably (closely
associated with the concept of
ethics)
• Derived from the Latin
“mores”, means custom or
habit.
• Morality: usually refers to an
individual’s personal standards
of what is right and wrong in
conduct, character, and
attitude.
• Morals: are based on religious
beliefs and social influence
and group norms
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Morals and Ethics (continue)
• Ethics is a branch of philosophy (the study of beliefs and
assumptions) referred to as moral philosophy.
• Derived from the Greek word “ethos” which means
customs, habitual usage, conduct and character.
• Ethics: usually refers to the practices, beliefs, and
standards of behavior of a particular group such as
nurses. It also refers to the method of inquiry that
assists people to understood the morality of human
behavior (study of morality)
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Morals and Ethics (continue)
• In both, we describe the behavior we observe as good,
right, desirable, honorable, fitting or proper or we might
describe the behavior as bad, wrong, improper,
irresponsible, or evil.
[Such perceptions are based on values]
• There are times when a differences in values and
decisions can be accepted
• Differences in values and decisions put people into direct
conflict.
What to do in such situation?
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Morals and Ethics (resolving conflicts)
• Be constructive (rather than destructive) in the methods you
choose to work toward resolving the differences
• Listen carefully without interruptions
• Seek clarification using gentle questioning
• Respect cultural differences
• Be attentive to body language
• Explain the context of your point of view and try to picture
the other person’s expective of what you are saying
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Comparison of morals and ethics
Morals
• Principles and rules of right
conduct
•
•
• Private, and personal
• Commitment to principles
and values is usually
defended in daily life
• Pertain to an individual‘s
character
•
•
•
Ethics
Formal responding process used
to determine right conduct
Professionally and publicly
stated
Inquiry or study of principles and
values
Process of questioning, and
perhaps changing, one’s morals
Speaks to relationships between
human beings
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Moral development
• Moral development is a complex process that is not
fully understood
• It is the process of learning what ought to be done
and what ought not to be done
• Different approaches to moral development exists:
• Kohlberg’s theory
• Gilligan
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Moral distress
• When the nurses are unable to follow their moral beliefs
because of institutional or other restriction.
• The distress occurs when the nurse violates a personal
moral value and fails to fulfill perceived responsibility.
• Moral distress represent practical, rather than ethical
dilemmas.
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Moral outrage
- Occurs when someone else in the health care setting
performs an act the nurse believes to be immoral.
- Nurses do not participate in the act.
- Nurses not responsible for wrong but perceive that they
are powerless to prevent.
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Kohlberg Approach
• Directly affected by Piaget’s theory of cognitive
development
• Focuses on the structure of though about moral
issues rather than the specific content of moral
values.
• Emphasizes fairness, rights and autonomy in a
justice framework
• Moral development progresses through three levels:
• Level I: premoral or preconventional level
• Level II: conventional level
• Level III: post conventional, autonomous or
principled level
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Gilligan’s theory
• Focuses on a care perspectives
• Organized around the notions of responsibility,
compassion (care), relationships
• The ethics of justice (fairness) is based of the idea of
equality “everyone should receive the same treatment”.
By contrast, the ethics of care is based on a premise of
nonviolence: that no one should be harmed or
abandoned
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Gilligan’s theory (continue)
• Process of developing an “ethics of care”
• Stage I: caring for oneself
• Stage II: caring for others
• Stage III: caring for oneself and others
• Each stage ends with a transitional period (a
time when the individual recognizes a
conflict or discomfort with some present
behavior and considers new approaches)
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Moral/ethical principles (concepts)
• Are statements about
broad, general
philosophic concepts
such as autonomy and
justice
• They provide the
foundation for moral
values, which are
specific prescriptions
for actions (e.g. “people
should not lie” (rule) is
based on the moral
principle of respect of
autonomy for people.
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Basic ethical concepts
1.
2.
3.
4.
5.
6.
7.
Rights
Autonomy
Beneficence and
Nonmaleficence
Justice
Fidelity
Veracity
The standard of
best interest
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Basic ethical concepts
Rights
•
Rights form the basis of most
professional codes and legal
judgments
• Self-determination rights
•
Rights and cultural
relativism
•
Rights of the unborn
•
Rights of privacy and
confidentiality
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Basic ethical concepts
Autonomy
•
•
•
•
Involves the right of self-determination,
independence, and freedom.
It refers to the right to make one’s own
decisions
Respect for autonomy means that nurses
recognize the individual’s uniqueness,
the right to be what that person is, and
the right to choose personal goals
Nurses who follow the principle of
autonomy respect a client's right to make
decisions even when those choices
seem not to be in the client’s best interest
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Basic ethical concepts
Autonomy….. (continue)
•
•
•
Respect for people also means treating others with
consideration
In the clinical setting, this principle is violated when a
nurse disregards client's subjective accounts of their
symptoms (e.g. pain)
Patients should give informed consent before tests and
procedures are carried out
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Basic ethical concepts
Beneficence and Nonmaleficence
Beneficence: means “doing good”
•
Nurses should implement actions that benefit
clients and their support persons. However, in an
increasing technologic health care system, doing
good can also pose a risk of doing harm (e.g.
intensive exercise program).
Nonmaleficence: means the duty to do no harm.
•
This is the basic of most codes of nursing ethics.
•
Harm can mean deliberate harm, risk of harm, and
unintentional harm.
•
In nursing, intentional harm is always
unacceptable.
•
The risk of harm is not always clear
•
A client may be at risk of harm during a nursing
intervention that is intended to be helpful (e.g.
medication)
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Basic ethical concepts
Justice
•
•
•
Is often referred to as fairness
Nurses frequently face decisions in which a
sense of justice should prevail (succeed)
E.g. busy unit, new admission
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Basic ethical concepts
Fidelity
•
•
•
Means to be faithful to agreements and
responsibilities one has undertaken
Nurses have responsibilities to clients,
employers, government, society, the
profession, and themselves
Circumstances often affect which
responsibilities take precedence at a
particular time
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Basic ethical concepts
Verasity
•
•
•
•
Refers to telling the truth
As a nurse should I tell the truth when it
is known that doing so will cause harm?
Does tell a lie when it is known that the
lie will relieve anxiety and fear?
Should I lie to dying people?
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Basic ethical concepts
The standard of best interest
•
Applied when a decision must be made
about a patient’s health care and the
patient is unable to make an informed
decision
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Ethical theory
• An ethical theory provides a framework within
which agents can reflect on the acceptability of
actions and can evaluate moral judgments and
moral character
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Ethical theories
1- Teleology
2- Deontology
3- Institutionism
4- Ethic of caring
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Ethical theories….(continue)
Teleology: looks to the consequences of an action in judging whether
that action is right or wrong
Deontology: proposes that the mortality of a decision is not
determined by its consequences. It emphasizes duty, rationality,
and obedience to rules
The difference between Teleology and Deontology can be seen when
each approach is applied to the issue of abortion
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Ethical theories…..(continue)
Example:
Teleology approach/abortion: saving the mother’s
life (the end, or consequence) justifies the
abortion (the mean, or act)
Deontology approach/abortion: consider any
termination of life as a violation of the rule “do
not kill” and therefore, would not abort the fetus,
regardless of the consequences to the mother
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Ethical theories…..(continue)
Institutionism: summarized as the notion that people
inherently know what is right or wrong; determining what
is right is not a matter or rational thought or learning
(e.g. the nurse inherently knows it is wrong to strike a
client, the nurse does not need to be taught this or to
reason it out)
The preceding three theories are based on the concept of
fairness (justice)
Ethic of caring: it is based on relationships.
Caring is a force for protecting and enhancing client dignity
Caring is of central importance in the client-nurse
relationship (e.g. nurses use trust-telling to affirm clients
as a persons rather than objects and to assist them to
make choices and find meaning in their illness
experiences)
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Guidelines for Ethical Reasoning
 Stay open-minded. Challenge your own views. It’s
not enough just to hold a position, you must be able
to support it with good reasons.
 Challenge the views of others if you disagree with
them, but do so respectfully and considerately.
 Philosophical discussion loses most of its value if
it’s used as a place to dominate or show off.
 Philosophical discussion is best done as a
community enterprise, where all the discussants
work together to get closer to the truth.
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Nursing Codes of Ethics
• A code of ethics is a formal statement of a group’s ideals and values.
• It is a set of ethical principles that is shared by members of the
group, reflects their moral judgments over time and serves as a
standard for their professional actions.
• Codes of Ethics are usually higher than legal standards
• International, national, state nursing associations have established
codes of ethics
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Nursing Codes of Ethics (purposes)
1.
2.
3.
4.
5.
6.
To inform the public about the minimum standards of
the profession and to help them understand
professional nursing conducts
To provide a sign of the profession’s commitment to
the public it serves
To outline the major ethical considerations of the
profession
To provide general guidelines for professional behavior
To guide the profession in self-regulation
To remind nurses of the special responsibility they
assume when caring for clients.
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Nursing Codes of Ethics (elements)
• Nurses have four
fundamental
responsibilities: to promote
health, to prevent illness, to
restore health, and alleviate
suffering.
• Nurses and people
• Nurses and practice
• Nurses and the
profession
• Nurses and the coworkers
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What is Ethical Decision Making?
• When faced with an ethical dilemma the objective is
to make a judgment based on well-reasoned,
defensible ethical principles.
• The risk is poor judgment i.e. a low-quality decision
• A low-quality decision can have a wide range of
negative consequences
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Two Types of Ethical Choices
• Right vs wrong: choosing right from
wrong is the easiest
• Right vs right
• Situation contains shades of gray
i.e. all alternative have desirable
and undesirable results
• Choosing “the lesser of two evils”
• Objective: make a defensible
decision
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Factors that influence EDM
1.
2.
3.
4.
5.
6.
7.
8.
Codes for Nurses
The patient’s rights
Social and cultural attitudes
Science and technology
Legislation
Judicial decisions
Funding
Personal religious and philosophic
viewpoint
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Factors in the work environment that
affect EDM
1.
2.
3.
4.
5.
6.
Status as an employment
Collective bargaining contracts
Collegial relationships
Authoritarian and paternalistic
background
Ethics committees in health care
Consumer involvement in health
care
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A framework for Ethical Decision
Making (EDM)
1.
2.
3.
4.
5.
Identify and clarify the ethical problem
Gather data
Identify options
Make a decision
Act and assess
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Making Moral Decisions--Some
Inappropriate Ways:
• Appeal to Authority
• Appeal to Law
• Appeal exclusively to self-interest
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Some Guidelines for Making
Ethical Decisions
1. Choose correct moral language.(Often, the way in
which you initially
conceptualize a situation will affect
what moral conclusions you will make)
2. Be as clear as you can about the facts, both empirical
and philosophical
3. Consider the relevant moral principles and rules, and
make your best judgment.
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Ethics Committees
With the increasing complexity of ethical issues in health care,
ethics committees have been created to assist in making
ethical decisions in clinical settings. Ethical committees
can:
1. Provide structure and guidelines for potential problems.
2. Serve as an open forum for discussion and debate.
3. Function as a patient advocate by placing the patient at the
core of the committee’s deliberations.
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Discussion Questions
• Is the patient’s decision a rational one?
• What is the difference between withholding and
withdrawing life-sustaining treatment?
• In view of the fact that a potent sedative such as
morphine may produce respiratory depression, should
this be given prior to discontinuing the respirator?
Would this constitute active euthanasia?
• Would the situation be different if Mrs. C. had a living
will?
• What role could the nurse play in addressing the ethical
issues in this case?
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notes
• Euthanasia
Greek words meaning “easy death”.
Euthanasia is an act by which the causative agent of
death is administered by another with the intent to end
life.
Killing an innocent person, even at his or her request is
not ethical.
“Code for Nurses (1985) and the ANA position statement
(1994) states that the nurse should not participate in
euthanasia but be vigilant advocates for the delivery of
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dignified and human care.
• Living Wills
Prepared while patient has decisional capacity
Describes patient preferences in the event they
become incapable of making decisions or
communicating decisions.
Usually describes what type of life prolonging
procedures the patient would or would not
want and circumstances under which they
would want these procedures carried out,
withheld, or withdrawn
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