Chapter 9
Ethical and Bioethical Issues in
Nursing and Health Care
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Nursing Ethics

Definition: system of principles that govern the actions of the nurse
in relation to patients, families, other health care providers, policy
makers, and society
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Nursing Ethics

Code of ethics
 Implicit standards and values for the profession
 American Nurses Association Code of Ethics
 International Council of Nurses Code for Nurses
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Bioethics

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
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Bioethics

Dilemmas for health professionals
 Life and death
 Quality of life
 Right to decide
 Informed consent
 Alternative treatment issues
 Stem cell research
 Reproductive assistive technology; donor insemination
 In vitro fertilization
 Surrogate motherhood
 Organ transplantation
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Bioethics

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
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Ethical Decision Making

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?
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Ethical Decision Making

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.
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Ethical Decision Making

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 nursepatient relationship.
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Values Formation and
Moral Development

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
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Values Formation and
Moral Development

Examining value systems
 Nurses must examine their own value systems.
 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
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Values Formation and
Moral Development

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
 Have learned that good behavior is rewarded and bad
behavior is punished
 Begin to make choices that are based on an
understanding of good and bad
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Values Formation and
Moral Development
• Adolescent
Questions existing moral values and his or her
relevance to society
 Becomes more aware of contradictions in adult’s value
systems
• Adult
 Strives to make sense of the contradictions and learns
to develop his or her own set of morals and values
 Begins to make choices that are based on an
internalized set of principles

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Values Formation and
Moral Development

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
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Values Formation and
Moral Development

Moving toward moral maturity
• Quality of complex health care decisions depends on the
level of moral development of the professionals entrusted
with decision making.
• Seven values are essential for the professional nurse:
 Altruism—concern for the welfare of others
 Equality—having the same rights, privileges, or status
 Esthetics—qualities of objects, events, and persons that
provide satisfaction
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Values Formation and
Moral Development
Freedom—capacity to exercise choice
 Human dignity—inherent worth and uniqueness of a
person
 Justice—upholding moral and legal principles
 Truth—faithfulness to fact or reality
• Ethical theory and ethical principles can provide a basis for
moving forward as a morally mature professional adult.

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Ethical Theory

Definition: a system of principles by which a person can determine
what ought and ought not to be done
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Ethical Theory

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?
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Ethical Theory

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.
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Ethical Principles

Purpose of ethical principles
 Establish common ground between 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
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Ethical Principles

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.
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Ethical Principles

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.
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Ethical Principles

Nonmaleficence
 Implies a duty not to inflict harm
 To abstain from injuring others
 To help others further their own well-being by removing harm
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Ethical Principles

Veracity
 Principle of truth-telling
 The belief that truth could at times be harmful to patients was
held for many years.
 Health care consumers today expect accurate and precise
information revealed in an honest and respectful manner.
 For trust to develop between providers and patients, truthful
interaction and meaningful communication must occur.
 The challenge is to mesh the need for truthful communication
with the need to protect.
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Ethical Decision-Making Model

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?
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Ethical Decision-Making Model

Identify and analyze available alternatives for action.
• What are the reasonable possibilities for action?
• How do the different 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, if any, additional ethical problems are raised by the
alternatives?
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Ethical Decision-Making Model

Select one alternative.
• Integration of multiple factors
• A reasonable and purposeful decision results from the
blending of ethical theory, principles, and values.
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Ethical Decision-Making Model

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.
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Ethical Decision-Making Model

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.
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Ethical Decision-Making Model


Applicable to the daily practice level of ethical decision making
Applicable to the policy-making level, where professionals
come together to consider right and wrong choices that affect
society as a whole
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Bioethical Dilemmas: Life, Death,
and Dilemmas In Between

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.
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Bioethical Dilemmas: Life, Death,
and Dilemmas In Between

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
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Bioethical Dilemmas: Life, Death,
and Dilemmas In Between

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 also present new ethical
questions.
 Nurses in every setting must be prepared to consider end-of-life
questions.
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Bioethical Dilemmas: Life, Death,
and Dilemmas In Between

Dilemmas in between
 Right to health care
• Health care system has become 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.
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Bioethical Dilemmas: Life, Death,
and Dilemmas In Between

Allocation of scarce resources
• Should the recipient of scarce resources be selected on the
basis of quality of life? Ability to pay? Best prognosis? Firstcome, first-served?
• Nurses should be prepared to consider questions regarding
allocation of scarce resources.
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Ethical Challenges

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 the patient be made aware of questions and various
options surrounding care?
 Is disclosure of uncertainty beneficial or detrimental?
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Ethical Challenges

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
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Ethical Challenges

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 elderly, mentally compromised, imprisoned,
inebriated, unconscious, and those in emergency situations.
 Nurses also must take responsibility for understanding and
educating people about advance directives.
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Ethical Challenges

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.
 The obligation to denounce a harmful action or a 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.
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