What are morals?
Private, personal, or group standards of right and wrong. Broad and general - good vs bad, i.e. it is wrong to steal
What is moral behavior?
Behavior that is in accordance with custom or tradition and usually reflects personal or religious beliefs.
An example of morality.
the golden rule" or opposition or support of abortion
Define ethics.
A systematic study of right and wrong conduct in situations that involve issues of values and morals.
Define ethics
A formal process for making logical and consistent moral decisions. Uses specific rules, theories, or principles, and perspectives to inquire into the justification of a person's actions in a particular situation. Answers, "What should I do in a given situation?
Ethics and law
Not the same. A legal action may not be morally right and vice versa. Example: Speeding - illegal. But, trying to get hemorrhaging child to hospital. Does it make it immoral? Right?
Bioethics
Application of ethical principles to healthcare. - Direct care, staff, medical and nursing research
Nursing ethics
Subset of bioethics. Ethical questions that arise out of nursing practice
Nursing responsibility in ethical issue
You are responsible for deciding the nature and extent of your own participation and support pts. making ethical decisions or coping with results of decisions made by others.
Why study ethics?
1. It will come up a lot. "Should I do this?"
2. Central to nursing. Health and compassion are central values.
3. Multidisciplinary input important.
4. Ethical knowledge needed for competence
5. Ethical reasoning needed for credibility - need to be able to express moral position to be accountable. Need to understand your own values as they relate to morality
6. Essential for providing holistic care
7. Patient advocacy
8. Helps you make better decisions - allows you to analyze moral problems from multiple perspectives not just your own
Advocacy
Communication and defense of the rights and interests of another - protect legal and moral rights by identifying the ethical issue and communicate patient's wishes
Moral or ethical agency
The ability to base nursing practice on professional standards of ethical conduct and participate in ethical decision-making. You have choices and are responsible for your actions.
What are the 5 components of ethical agency?
1. Know right from wrong
2. Understand moral principles
3. Reason and apply moral principles to make decisions, weigh options, and plan ways to achieve goals
4. Decide and choose freely
5. Act according to choice
Moral distress
Result of making ethical decision that can't be carried out
Examples of obstacles to carrying out moral decisions
MDs, other staff, policies, threat of lawsuits, doubting own knowledge, being socialized to follow orders, administration
Define whistleblower
A person who identifies an incompetent, unethical, or illegal situation, or actions of others, in the workplace and reports it to someone who may have the power to stop the wrong
Moral outrage
What is experienced when it is perceived that others are behaving immorally
Impaired nursing practice
The nurse's ability to perform is diminished by drugs, alcohol, or mental illness.
Societal factors that cause ethical problems
1. Increased consumer awareness - we are to share knowledge with pts. and obtain informed consent instead of them blindly doing what the MD ordered
2. Technological advances - organ transplants, stem cell research, cryogenics are examples
3. Multicultural population - different value sets
4. Cost containment - less staffing, quicker discharges
Nature of nursing work that cause ethical problems
1. Own moral problem - not acting is the same as acting, i.e. to code or not to code
2. Conflicting loyalties - agency, patient, peer, MD relationships. Example - test results to p.t when MD doesn't want to tell. Loyal to MD or pt.?
Nature of nursing profession that cause ethical problems
1. Caring vs time spent with pt.
2. Autonomy vs escaping hard choices
3. Higher pay vs cost effectiveness
4. Professionalism vs caring
Kohlberg's preconventional level of moral development
Person conforms to cultural rules and labels of good and bad but interprets them in terms of punishment and reward or the physical power of those who enforce the rules. Kids 4-10
Kohlberg's stage 1 of moral development
Punishment-obedience. It's right if it avoids punishment
Kohlberg's stage 2 of moral development
Personal interest orientation - It's right if it satisfies your own personal needs
Kohlberg's stage 3 of moral development
Good boy - nice girl orientation. It's right if it pleases others
Kohlberg's stage 4 of moral development
Law and order orientation. It's right if it follows the rules
Kohlberg's stage 5 of moral development
Legalistic, social contract orientation. Right is determined in terms of individual rights and standards agreed on by society
Kohlberg's stage 6 of moral development
Universal ethical principles orientation - a right action is determined by conscience and abstract principles such as the golden rule
Kohlberg's conventional level of moral development
Meeting family/societal expectations is valuable, regardless of consequences of actions. Others set the standards but the person is internally motivated to follow
Kohlberg's postconventional, autonomous, or Principled level of moral development
Person defines moral values and principles that have validity apart from society or persons in power. May experience conflict between 2 acceptable standards and try to decide rationally between the 2. Both standards and decision are internal. Moral principles have validity apart from the authority of groups/persons.
Define values
A belief you have about the worth of something; serves as a principle or standard that influences decision-making
Define values
Ideals, beliefs, customs, modes of conduct, qualities, goals that are highly prized or preferred.
Criteria for "full value
1. Chosen freely from list of options after consideration of consequences of each
2. Cherished and made known to others
3. Translated into behaviors that are consistent with chosen value and part of lifestyle
Characteristics of values
Taken for granted, learned consciously and unconsciously, part of person's makeup, individual or shared, vary person to person, change over time, expressed overtly or indirectly
Define value set
Your "list" of values - Forms basis for behavior and directs life
Define attitudes
Mental dispositions or feelings toward a person, object or idea. Cognitive, affective, and behavioral.
Define beliefs
Something that one accepts as true. Sometimes based on faith and/or facts. May or may not involve values.
Personal value system
A set of values you have reflected on and chosen to help you lead a good life. May include societal values such as saying "Please" and personal values such as friendship, fairness
Professional values
Expansion of personal values based on learning and experience professionally
Name the 6 professional values of the AACN
1. Altruism: Concern for the well-being of others
2. Autonomy: right to self-determination - to choose and act on that choice
3. Human dignity: respect for inherent worth and uniqueness of others
4. Integrity: act in accordance with code of ethics and standards of practice. Honesty
5. Social justice: uphold moral, legal, and humanistic principles. Treat fairly regardless of sex, race, age, etc.
Value neutrality
We attempt to understand our own values regarding an issue and know how to put them aside to be nonjudgmental when caring for pts.
Name the 5 ways that values can be transmitted.
1. Modeling: learn by observation - good and bad
2. Moralizing: "this way is the only way." Authoritarian. Doesn't allow for independent choices.
3. Laissez-faire: "Doing your own thing." May lead to conflict and confusion
4. Reward and punishment: Behavior controlled with rewards for certain valued behaviors and punish the failure to comply
5. Responsible choice: Balance of freedom and restriction - allows selection of values, explore new behaviors, and experience consequences
Moral frameworks
Systems of thought (theories) that are the basis for differing perspectives people have in ethical situations.
Altruism
Demonstrates understanding of cultures, beliefs. Advocates for pts. Mentors others. Takes risk on behalf of pts. peers
Autonomy
Plans care with pts. Honors pt./family right to make decisions. Provides info to make informed choices. Informs pts.of care details, I.e. lab results
Human dignity
Provide culturally competent/sensitive care. Protects pt. privacy. Preserves confidentiality. Sensitive to pt. needs. Values/respects pt./peers
Integrity
Provide honest info. Document accurately. Remedy errors by self and others. Accountable for actions
Social justice
Support fairness and nondiscrimination. Promote universal access to healthcare. Works to ensure equal treatment under the law.
Consequentialism
The rightness or wrongness of an action depends on the consequences of the act rather than on the act itself
Teleology
Ethics theories the "study of ends" - Consequentialism is an example with utilitarianism a type of consequentialism
Utilitarianism
Type of consequentialist theory - the value of an action is determined by its usefulness. Ex. risks vs benefits
The principle of utility
An act must result in the greatest good for the greatest number of people
Example of consequentialism
First, do no harm
Steps in solving ethical issue using utilitarianism
1. List pros and cons
2. Select action that benefits the most people
Ex. Triage
Deontology
Opposite of utilitarian. Considers action right or wrong regardless of consequences. Decisions based on moral rules/principles.
Name/describe deontological theories
1. Kantianism: act only if the act is based on a universal principle - you believe everyone should act in the same way in a similar situation
2. Treat people as ends and never as means: The person is more important than the goal. EX. don't expose people to research drugs in hopes of benefitting many
3. Rules and principles: comes from religion, i.e justice, autonomy, doing good, doing no harm
4. Rights and duties: Ex. you must help someone in need because you have a duty to help others, not because helping will produce good consequences
Difficulties in using deontological theories
1. Conflict of universal principles: Must choose between 2 conflicting universal principles and not always clear which to pick. Ex. no blood transfusion for JW child. principle of autonomy vs child's right to life
2. Hard to know others' motives: why no blood? Based on religion or inherit trust fund?
Feminist ethics
Based on belief that traditional ethical models provide a masculine perspective and devalue the moral experience of women. Men value fairness, justice and rights as seen in theories. Women value love, relationships, caring, nurturing, and sympathy. Believe distracts from larger social issues.
What is used in Feminist ethical reasoning
relationships and stories instead of universal principles. Can't avoid relationship influences, which they see as positive and shouldn't be lessened by objectivity, which they deem impossible to achieve.
What is the thrust of feminist ethics?
Look at social issues to make sure social facts considered and address issues of gender inequality within each situation. EX. funds to young vs old people: Feminist reasoning would say more older women than men, older women poorer and more alone than men, if healthcare for elderly rationed, it would negatively impact more women than men, therefore, it would be unfair and unethical to give more funds to young than old
What is ethics-of-care?
Nursing philosophy . Attention to specific situation of pts. within the context of their life. Emphasizes feelings but includes autonomy and beneficence.
What is the nurse's responsibility in ethics-of-care?
Ability and duty to appreciate, understand, and share patient's pain or condition. Responsibility to care. Ethical analysis focuses on relationships and client stories
Name specific ethics-of-care perspectives
1. View caring as the central force
2. Promote dignity and respect for pts. as people
3. Attend to particulars of each pt. - even "bad" pts.
4. Cultivate responsiveness to others
5. Redefine fundamental moral principles to include kindness, attentiveness, empathy, compassion, reliability
Advantage of ethics-of-care perspective
Focuses discussion on caring, pt. stories and relationships rather than intellects. Ex. free care to homeless? or later hospital DC when people are healthier? This model would say yes.
Autonomy
A person's right to choose and ability to act on that choice. Respect for human dignity.
Examples of autonomy
Informed consent, Treat pts. with consideration, believe their symptoms and protect those who can't protect themselves. Inform re adv. directives, respect pt. decision even if against your beliefs. Privacy and confidentiality - pt. has right to won records and info. shared
Nonmaleficence
Duty to do no harm and prevent harm including actual harm and risk of harm, intentional and unintentional (due to lack of skill/knowledge/planning). Weigh benefits vs risks. INcludes respect for dignity.
Examples of nonmaleficence
Prevent med errors, provide walker, use gait belt to amb. pt., premedicate post-op pt. before amb.
Respect for dignity
Respect for the intrinsic worth of each person, without respect for age, race, religion, etc.
Examples of respect for dignity
Taking into account cultural and spiritual values, customs, and beliefs as well as social and economic circumstances. Don't take advantage of vulnerable pts. - no romance, sex, $, etc.
Beneficence
Duty to do or promote good
Examples of beneficence
1. Do no harm - don't push man in river
2. Prevent harm when you can - warn him he's at the edge and about to fall into river
3. Remove harm when being inflicted - If see someone trying to push him in, try to stop if can do without harm to self
4. Bring about positive good - jump in and get him or call 911 and throw life-line if can't swim
Paternalism
Treating others like children. Happens when you think you know what is best for pt. and make them do what you want instead of what they want - lacks respect for autonomy
Fidelity
The duty to keep promises
Veracity
Duty to tell the truth - hard to determine how much truth to tell and risk losing pt. trust. Be mindful of cultural values and consider the context.
Justice
The obligation to be fair - equal tx. of all pts.
Distributive justice
Fair distribution of benefits and burdens
a. Allocating resources - who gets the new liver?
b. Fair access to care - Who gets access to limited resources and funds?
Compensatory justice
Focus on making amends for wrongs done to individuals or groups. Ex. malpractice suits
Procedural justice
first come, first served." Used in processes that require ranking or ordering. Ex. hospital policies so same procedures apply to all pts. or employees in same way (visiting hrs, sick leave, etc.)
Name the 6 ethical principles - make sure you can describe each too!
Autonomy, nonmaleficence, beneficence, fidelity, veracity, justice
Define Professional Code of Ethics
Formal statements of a group's expectations and standards for professional behavior generally accepted by members of the profession. Not legally binding but Board can use to discipline
Purpose of Nursing Code of Ethics
1. Inform public about profession's minimum standards
2. Demonstrate nursing's commitment to public it serves
3. Outline major ethical considerations for nursing
4. Provide general guidelines for professional behavior
5. Guide the profession's self-regulating functions
6. Reminder of responsibility assumed in caring for sick
ANA Code of Ethics
1. Practice with compassion and respect for inherent dignity/worth/uniqueness of all regardless of sex, race, etc.
2. Primary commitment is to pt. whether individual, family, group or community
3. Promotes, advocates for, and tries to protect health, safety and rights of pt.
4. Responsible/accountable for own practice and delegates appropriately consistent with obligation to provide optimal care
5. Owes same duties to self as to others including preserving integrity, safety, maintain competence and pursue personal/professional growth
6. Participates in establishing, maintaining and improving health care and conditions of employment consistent with values of profession for the provision of quality care
7. participates in advancement of profession through contributions to practice, educ., administration, and knowledge
8. Collaborates with other healthcare professionals and public to promote efforts to meet health needs
9. Articulate nursing values for maintaining integrity of profession and for shaping social policy
ANA standards of care
standards for clinical practice, including ethics
Patient Care Partnership
Pts. entitled to rights in terms of treatment: to be active partners in tx process, make own decisions, be treated with dignity and respect. Encourages providers to be more aware of need to treat pts. ethically and to protect their rights. Includes clean, safe environment, confidentiality, review of bill, follow-up care and self-care after DC
Joint Commission Standards require hospitals do what?
1. Manage pts/public ethically
2. Consider pt's values/preferences re discontinuing care, tx
3. Help understand and exercise pt rights
4. Inform pt. of their responsibility in care and tx.
5. Recognize hospital's legal responsibilities
Name at least 8 ethical issues in healthcare
AIDS, Abortion, Confidentiality/privacy, Advance directives, DNR orders, assisted suicide/euthanasia, withdrawing/withholding life support, informed consent, organ transplantation, compelling unwanted tx, reproductive technology, heroic measures to prolong life, allocation of resources
Nursing diagnoses for pts struggling with moral issues
1. Decisional conflict - pt. uncertain about course of action to take. physical signs of distress, delay decision-making, question own beliefs, etc.
2. Moral distress - pt. made a moral decision but unable to carry out action. Express powerlessness, guilt, anxiety, frustration, fear, self-doubt
Values clarification
Process of becoming conscious of and naming one's values
What are the steps of values clarification?
1. Beliefs are chosen (cognitive)
2. Chosen beliefs/behaviors are prized (affective)
3. Beliefs are acted upon (behavioral)
Define ethical dilemma
A situation in which a choice must be made between 2 equally undesirable actions. No clearly right or wrong option.
Describe a systematic approach for resolving ethical dilemmas
1. Assessment - What are the relevant facts?
2. Analysis/Diagnosis - Identify problem and state the conflict
3. Apply MORAL model to find options
Describe the MORAL model steps
M - Massage the dilemma
a. Identify and define issues, consider values/options of all involved
b. Identify information gaps
O - Outline options
R - Resolve the dilemma by applying moral principles
A - Act by applying chosen option
L - Look back and evaluate process not just consequences
Role of nurse in client advocacy
1. Talk to p.t/family/clergy about their thoughts
2. Ensure all viewpoints heard, respected and considered
3. Look for a good compromise that preserves the integrity of all parties and is ethically sound
Describe why compromise is good.
1. Don't settle by use of force - protects rights of less powerful party i.e. no court order to force transfusion
2. Keeps peace on nursing unit
3. Seeing others' perspectives keeps us open-minded and less judgmental
4. Most issues allow differences of opinions
5. Helps achieve mutual respect
Nurse obligations in ethical decisions
1. Be aware of and sensitive to issues
2. Assume responsibility for own moral actions
3. Function as team member
4. Support pt/family including pts not allowed or able to decide
5. Use/participate in ethics committees
6. Advocate for pt.
Role of Ethics Committee and who is on it
Nurses, MDs, clergy, ethicists, lay reps.
Develop guidelines/po9licies, provide education/counseling/ review ethical cases and allow for expression of everyone's perspectives
Describe the 3 models used by ethics committees
1. Autonomy model: Pt competent to decide. Emphasizes pt autonomy and choice as highest value
2. Patient Benefit Model: Uses substituted judgment for incompetent pt.
3. Social Justice Model: Focuses on broad social issues in entire hospital instead of 1 patient issue, i.e. should the hospital ever seek legal order to act against parent's wishes?
Describe integrity-producing compromise
Discussion are carried out with mutual respect - all viewpoints respected and considered. Compromise solution is ethically sound meaning there should be principles-based rational for compromise
Why is pt. advocacy important?
1. You have knowledge the pt. doesn't
2. Your role is to defend pt's autonomous decisions per ANA Code of Ethics even if don't agree
3. Nurses have special pt. relationships
4. Role of advocate is to inform, support and communicate
5. Ask and inform re advance directives