Running head: ETHICAL DILEMMA IN THE WORKPLACE
Ethical Dilemma In The Workplace
James Corder
Frontier School of Midwifery and Family Nursing
November 10, 2010
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ETHICAL DILEMMA IN THE WORKPLACE
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Ethical Dilemma in the Workplace
Nurses commonly face ethical decisions in their practice. Ethics are based on
knowledge, which are formulated from the philosophical study of right and wrong and it is not
just an opinion. Moreover, an ethical dilemma occurs when two or more ethical principles
conflict with one another and a correct decision is not obvious (Kelly, 2010 p. 344). I chose the
following situation because it best allows me to reflect on an ethical dilemma that I experienced
personally; discuss who was involved, how it was handled, and apply personal and professional
values. In addition, talk about what I might do differently if I were the nurse leader; offer a
decision-making guide, and discuss relevant ethical principles that relate to this particular
dilemma.
This ethical dilemma took place when I worked home health in the early 1990’s. The
incident involved an elderly patient, a co-worker, our supervisor, and a physician. This elderly
woman had dementia and lived with her son who was also a physician and her power of attorney
(POA). She was very ill, bed-ridden and constantly in and out of the hospital. The son had
decided that his mother would not go back to the hospital, but could instead receive treatment at
home. He insisted on a do not resuscitate order (DNR) for his mother, and request that she
receive no invasive treatments or feeding tubes other than her ongoing intravenous (IV) therapy.
One of this patient’s diagnoses was congestive heart failure (CHF) for which she was
routinely treated. Her acuity level kept increasing and any visit to this patient’s house was
challenging for she was very swollen and venous access was extremely difficult. The physician
was kind enough to make some house calls as well. It had become apparent that the prognosis
for this woman was not going to support any quality of life—she had lived much longer than
everyone had thought possible.
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One evening the patient’s team leader came into the office to discuss new orders she had
just received from the physician. The nurse said she reported to the physician a four plus edema,
increased shortness of breath with accessory muscle use, lung sounds decreased with rales in the
upper lung fields and what we referred to as a death rattle. The nurse expecting to receive an
order for a potent diuretic instead received an order for a two-liter bolus of IV fluid.
The supervisor went to meet with the physician concerning the new order and to receive
further confirmation. This dilemma had to be dealt with very carefully because in the small town
where we lived this physician was very well thought of, had a large family practice, and the
catalyst from which most of our 300+ patients originated. A nurse who upset this physician
could very easily lose her job. The nursing supervisor returned to the office with medical reason
as to why the order was received. The physician once again confirmed the order and implied that
it was because the patient was dehydrated, had not received any nutrition for days and she may
be starving to death. The nurse gave the fluids that evening and the patient died the next
morning. I heard one nurse insinuate that this was a mercy killing of sort.
If I had been the nurse leader, I would have encouraged this nurse to refuse to give the IV
bolus, because I would not support my staff in performing a treatment that I thought could be
unethical or that I would not do myself. Although there was no quality of life left I believe that
further review of the labs and another patient assessment might have proved that, the patient may
have not been dehydrated—starving maybe? How much longer the patient would have lived
with or without the IV fluids would be impossible to guess. Recent studies of life sustaining
treatment confirm that such interventions as artificial hydration and nutrition have little or no
effect on survival in end of life care (Reifsnyder et al., 2006 p. 5).
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We have at least two types of values, personal and professional. Kelly (2007) suggests
that it is important to understand our personal values because they give direction and meaning to
life—they are our individual position about behaviors, standards, truths and principles (p. 346).
Furthermore, our personal values offer bases for developing our professional nursing values that
include altruism, integrity, human dignity, autonomy, and social justice (Kelly, 2010 p. 344).
Because of personal and professional values, I would have found reason to avoid or refuse to
administer the IV bolus.
Because of professional values, I respectfully would tell the physician that I did not feel
comfortable giving the treatment, and that I believe nursing values and code of ethics could
prevent me from carrying out this act. Some nurses would not avoid this given the client’s poor
quality of life remaining and their own personal values. However, the American Nurses
Association (ANA) conclude that nurses are bound by the code of ethics, which provide values
or standards as a guide for our decision-making. In addition, these standards are non-negotiable
they can only be amended through a formal processes by the House of Delegates (ANA Code of
Ethics, 2010). According to the ANA code of ethics, nurses should focus on meeting the needs
of patients and their families; they should maximize patient values and minimize unwanted
treatments, while preventing and relieving suffering associated with dying (ANA Code of Ethics,
2010).
Rejecting the physician’s order would have been difficult for me because of learned
values to follow authority figures request, but I think values that I have obtained both personally
and professionally would have prevented me from carrying out his demand. Nurses who are
morally developed and mature perform based on respect and dignity for all people and not just
on respect for authority (Kelly, 2010 p. 344). Nurses should provide interventions to relieve pain
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and other symptoms in the dying patient, even when those interventions may appear to speed up
the dying process. However, nurses may not do anything that hastens death; act with the
intention of ending a patient’s life even if motivated by compassion, respect for autonomy, or
quality of time left (ANA Code of Ethics, 2010). In this dilemma, I believe the action interfered
with my personal and professional values or at least the way in which I interpret them.
Ethical dilemmas deals with choices between options that are all unfavorable, however,
there are guides to obtain a deeper and clearer understanding of the dilemma at hand (Dahnke
and Dreher, 2006 p. 2). According to Kelly (2010), a guide for better ethical decision making
would be to ask yourself a series of questions like those used for ethics testing at Bentley
College: Who could get hurt? Is this right? Would I tell a relative that it is ok? Does intuition
tell you that it just feels bad? Would you be ok with your decision posted on the front page of
the local newspaper (p. 347)? In addition, decision-making should include a guide for
identifying conflicting moral issues, moral perspectives, and consider participants desired
outcomes. Besides ethical testing and guides there are ethical principles or rules to help steer
decision making.
There are two ethical principles that relate to this dilemma that can help carry out better
decision making. The first principle is called beneficence, which is the obligation to other people
to maintain a balance between harms and benefits (Kelly, 2010 p. 348). Beneficence propose
that the results of ethical decisions should produce the most good and least harm to the client,
and is actually founded on the concept of “do no harm” (Arnold and Boggs, 2007 p. 49). I felt
that giving the client an IV bolus could have potentially caused harm to the client—which in my
perspective would have violated beneficence and possibly hastened death.
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The second ethical principle that relates to this scenario is advocacy. Advocacy can be
defined as the obligation to watch out for people and speak up for their rights (Kelly, 2010 p.
348). Arnold and Boggs (2007) Implies that good patient advocates follow a process through a
series of steps designed to overcome helplessness and powerlessness of clients (p. 156). The
nurse should first assess the patient’s needs to identify a problem situation. Once the dilemma is
recognized, the advocate develops a plan to address it—then implements the plan (Arnold and
Boggs, 2007 p. 156). When reflecting on the dilemma I questioned, did the patient have a good
advocate and was her rights violated? The fact that this patient was not my client and I was a
new graduate at the time does not change my responsibility to have been a better advocate for
this patient.
Nurses are patient advocates first, they have the obligation to speak up for the rights of
clients and provide high quality care (Kelly, 2010 p. 348). According to Arnold and Boggs
(2007), Nurses act as patient protectors and are increasingly requested in legal cases of
negligence and malpractice. In addition, nurses who within the scope of practice try to do
something instead of doing nothing are generally held less liable (p. 156). Client advocacy acts
as a connection between law and ethics so nurses must now be knowledgeable, able, and willing
to assert their opinion if poor medical management or care is suspected (Arnold and Boggs, 2007
p. 156).
I n review of this ethical dilemma some questions still remain—was this an act of mercy,
or did the physician really attempt to treat this patient’s condition?
Evidence was given that
nurses cannot participate in anything that could cause harm to a client or hasten death even if
motivated by compassion (ANA Code of Ethics, 2010). I showed how an effective nurse
manager could have implemented a guide for better ethical decision making, and have applied
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the ethical rules and principles of the profession as laid out by the ANA. I gave details as to how
that the ethical principles of beneficence and patient advocacy related to this situation.
The scenario gave me the opportunity to reflect on an ethical dilemma that I personally
experienced; discuss who was involved, how it was handled, and apply my personal and
professional values to the situation. In addition, it permitted me to explore what I might have
done differently if I were the nurse leader, present a guide to better decision-making, and discuss
the relevant ethical principles that related to this particular dilemma.
ETHICAL DILEMMA IN THE WORKPLACE
References
American nurses association (ANA) code of ethics. (2010). Retrieved from
http://nursingworld.org/
Arnold, E. C., & Boggs, K. U. (2007). Interpersonal communications: Professional
communication skills for nurses (5th ed.). St. Louis, Missouri: Saunders Elsevier.
Dahnke, M., & Dreher, H. M. (2006). Defining ethics and applying the theory: Applied ethics in
nursing. New York: Springer Publishing Company. 3, 13 pgs. Retrieved from
http://proquest.umi.com.ezproxy.midwives.org/
Kelly, P. (2010). Essentials of nursing leadership and management (2nd ed.). Clifton Park, NY:
Delmar Cengage Learning.
Reifsnyder, J., Lachman, V. D., Maxwell, T. L., Mahon, M. M., Taylor, C. S., Nunn, S. J., &
Capewell, U. H. (2006). End-of-life ethical issues: Applied ethics in nursing, New York:
Springer Publishing Company 193, 18 pgs. Retrieved from
http://proquest.umi.com.ezpoxy.midwives.org/pqdlink?did=1617096831&sid
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