Nursing Ethics

BY
Imran Yousafzai
Lecturer INS-KMU
 Nursing Ethics
• In the complex modern world, we are surrounded by
ethical issues in all facets of our lives.
• Consequently, there has been a heightened interest
in the field of ethics, in an attempt to gain a better
understanding of how these issues influence us.
• Specifically, in health care the focus on ethics has
intensified in response to controversial
developments, including advances in technology and
genetics, as well as diminished health care and
financial resources.
• Today, sophisticated technology can prolong
life well beyond the time when death would
have occurred in the past. Expensive
experimental procedures and medications are
available for attempting to preserve life, even
when such attempts are likely to fail. The
development of technological support has had
an influence on all stages of life.
• These advances in technology, however, have
been a mixed blessing.
• Questions have been raised about whether,
and under what circumstances, it is
appropriate to use such technology.
 Domain of Nursing Ethics
• The ethical dilemmas a nurse may encounter in the
medical surgical arena are numerous and diverse. An
awareness of underlying philosophical concepts will help
the nurse to reason through these dilemmas.
• Basic concepts related to moral philosophy, such as ethics
terminology, theories, and approaches, are included in this
chapter.
• Understanding the role of the professional nurse in ethical
decision making will assist nurses in articulating their
ethical positions and in developing the skills needed to
make ethical decisions.
 ETHICS THEORIES
• One classic theory in ethics is teleologic theory or
onsequentialism, which focuses on the ends or consequences
of actions. The most well-known form of this theory,
utilitarianism, is based on the concept of “the greatest good
for the greatest number.”
• The choice of action is clear under this theory, because the
action that maximizes good over bad is the correct one. The
theory poses difficulty when one must judge intrinsic values
and determine whose good is the greatest. Additionally, the
question must be asked whether good consequences can
justify any amoral actions that might be used to achieve them.
• Another theory in ethics is the deontologic or
formalist theory, which argues that moral standards
or principles exist independently of the ends or
consequences. In a given situation, one or more
moral principles may apply.
• The nurse has a duty to act based on the one
relevant principle, or the most relevant of several
moral principles. Problems arise with this theory
when personal and cultural biases influence the
choice of the most primary moral principle.
 APPROACHES TO ETHICS
• Two approaches to ethics are metaethics and
applied ethics. An example of metaethics
(understanding the concepts and linguistic
terminology used in ethics) in the health care
environment would be analysis of the concept of
informed consent.
• Nurses are aware that patients must give consent
before surgery, but sometimes a question arises
as to whether the patient is truly informed.
• Delving more deeply into the concept of
informed consent would be a metaethical
inquiry. Applied ethics is the term used when
questions are asked of a specific discipline to
identify ethical problems within that
discipline’s practice. Various disciplines use
the frameworks of general ethical theories
and moral principles and apply them to
specific problems within their domain.
 Ethical principles
• Common ethical principles that apply in nursing include
• autonomy,
• beneficence,
• confidentiality,
• double effect,
• fidelity,
• justice,
• nonmaleficence,
• paternalism,
• respect for people,
• sanctity of life
• veracity.
Common Ethical Principles

By
Imran Yousafzai
BSN, MSPH,PGHRHM,MHPE, MSN*
 Autonomy
• This word is derived from the Greek words
autos (“self ”) and nomos (“rule” or “law”),
and therefore refers to self-rule. In
contemporary discourse it has broad
meanings, including individual rights, privacy,
and choice. Autonomy entails the ability to
make a choice free from external constraints.
 Beneficence

• Beneficence is the duty to do good and the

active promotion of benevolent acts (eg,
goodness, kindness, charity). It may also
include the injunction not to inflict harm.
 Confidentiality

• Confidentiality relates to the concept of

privacy. Information obtained from an
individual will not be disclosed to another
unless it will benefit the person or there is a
direct threat to the social good.
 Double Effect
• This is a principle that may morally justify some actions
that produce both good and evil effects.
• All four of the following criteria must be fulfilled:
1. The action itself is good or morally neutral.
2. The agent sincerely intends the good and not the evil
effect (the evil effect may be foreseen but is not intended).
3. The good effect is not achieved by means of the evil
effect.
4. There is proportionate or favorable balance of good over
evil.
 Fidelity

• Fidelity is promise keeping; the duty to be

faithful to one’s commitments. It includes
both explicit and implicit promises to another
person.
 Justice

• From a broad perspective, justice states that like cases should be

treated alike. A more restricted version of justice is distributive justice,
which refers to the distribution of social benefits and burdens based
on various criteria that may include the following:
• Equality
• Individual need
• Individual effort
• Societal contribution
• Individual merit
• Legal entitlement
Retributive justice is concerned with the distribution of punishment.
 Nonmaleficence

• This is the duty not to inflict harm as well as to

prevent and remove harm. Nonmaleficence
may be included within the principle of
beneficence, in which case nonmaleficence
would be more binding.
 Paternalism

• Paternalism is the intentional limitation of

another’s autonomy, justified by an appeal to
beneficence or the welfare or needs of
another. Under this principle, the prevention
of evils or harm takes precedence over any
potential evils caused by interference with the
individual’s autonomy or liberty.
 Respect for Persons
• Respect for persons is frequently used
synonymously with autonomy. However, it
goes beyond accepting the notion or attitude
that people have autonomous choice, to
treating others in such a way that enables
them to make the choice.
 Sanctity of Life

• This is the perspective that life is the highest

good. Therefore, all forms of life, including
mere biologic existence, should take
precedence over external criteria for judging
quality of life.
 Veracity

• Veracity is the obligation to tell the truth and

not to lie or deceive others.
Nursing ethical values 

By
Imran Yousafzai
Lecturer, KMU-INS
• Ethical values offer a framework for behavior
assessment, and nursing values influence
nurses’ goals, strategies, and actions.
• Nurses as one of the health service providers and
members in health system who are responsible for
giving care to the clients and patients based on
ethical issues.
• They need ethical knowledge to conduct their
appropriate function to manage situations and to
give safe and proper legal and ethical care in today's
changing world.
• With regard to practical care, they always try
to answer the question of “What can I do?,”
whereas they should try to answer what is
essential to be done for the patients in the
context of ethical principles.
• Ethics seek the best way of taking care of the
patients as well as the best nursing function
• Nurses are responsible for their clinical function, and
their main responsibility is to take care of the clients
and patients who deserve appropriate and safe care.
• They act based on the values they have selected.
These values form a framework to evaluate their
activities influencing their goals, strategies, and
function.
• These values can also be counted as a resource
for nurses’ conduct toward clinical ethical
competency and their confrontation with
contemporary ethical concerns.
• Values conduct human life priorities and form
the world we live in. They act as one of the most
basic parts of human life.
• Ethical values are inseparable components of
the society and, as a result, nursing profession.
• Discovery of basic values and reaching an agreement
on clinical ethical values are essential with regard to
constant changes in nurses’ social class and role.
• Nurses’ awareness of their values and the effect of
these values on their behavior is a core part of
humanistic nursing care.
• They need to tailor their function to the value system
and cultural beliefs of their service recipients.
• Values originate from cultural environment, social
groups, religion, lived experiences, and the past.
• Social, cultural, religious, political, and economic
considerations influence individuals and their
value system, and ultimately, health, education,
social strategies, and patients’ care.
• Numerous documents have been prepared in
nursing texts and literature concerning these
values and clarification of their traits.
• Recognition and definition of nursing ethical
values in various communities can help nurses
have mutual understanding in international
level.
• It can also bring nurses closer to reach a
common meaning of care in patients with
different cultures.
• Human dignity
• Social justice
• Altruism
• Autonomy in decision making
• Precision and accuracy in caring
• Human relationship
• Responsibility
• Individual and professional competency
• Sympathy
• Trust
Ethical Decision making

By
Imran Yousafzai
Lecturer, INS-kmu
• Ethical principles are a set of standards that
help nurses make informed decisions when
evaluating the consequences of their actions.
• And another essential principle
of nursing practice is nonmaleficence, which
reminds us to cause no intentional harm to
patients.
 GATHER THE FACTS
• Don’t jump to conclusions without the facts
• Questions to ask: Who, what, where, when, how,
and why.
• However, facts may be difficult to find because of
the uncertainty often found around ethical issues
• Some facts are not available
• Assemble as many facts as possible before
proceeding
• Clarify what assumptions you are making!
 DEFINE THE ETHICAL ISSUE(S)
• Don’t jump to solutions without first
identifying the ethical issue(s) in the situation.
• Define the ethical basis for the issue you want
to focus on.
• There may be multiple ethical issues – focus
on one major one at a time.
– IDENTIFY THE AFFECTED PARTIES
• Identify all of the stakeholders
• Who are the primary or direct stakeholders?
• Who are the secondary or indirect
stakeholders?
• Why are they stakeholders for the issue?
• Perspective-taking -- Try to see things through
the eyes of those individuals affected
 IDENTIFY THE CONSEQUENCES
• Think about potential positive and negative consequences for affected
parties by the decision (Focus on primary stakeholders to simplify analysis
until you become comfortable with the process).
• What are the magnitude of the consequences and the probability that the
consequences will happen.
• Short term vs. Long term consequences – will decision be valid over time.
• Broader systemic consequences – tied to symbolic and secrecy
• Symbolic consequences – Each decision sends a message.
• Secrecy consequences – What are the consequences if the decision or
action becomes public?
• Did you consider relevant cognitive barriers/biases?
• Consider what your decision would be based only on consequences – then
move on and see if it is similar given other considerations.
 – IDENTIFY THE RELEVANT PRINCIPLES,
RIGHTS, AND JUSTICE ISSUES
• Obligations should be thought of in terms of principles and rights involved
• A) What obligations are created because of particular ethical principles you might
use in the situation?
• Examples: Do no harm; Do unto others as you would have them do unto you; Do
what you would have anyone in your shoes do in the given context.
• B) What obligations are created because of the specific rights of the stakeholders?
• What rights are more basic vs. secondary in nature? Which help protect an
individual’s basic autonomy?
• What types of rights are involved – negative or positive?
• C) What concepts of justice (fairness) are relevant – distributive or procedural
justice?
• Did you consider any relevant cognitive barriers/biases?
• Formulate the appropriate decision or action based solely on the above analysis
of these obligations.
CONSIDER YOUR CHARACTER & INTEGRITY
• Consider what your relevant community members would
consider to be the kind of decision that an individual of
integrity would make in this situation.
• What specific virtues are relevant in the situation?
• Disclosure rule – what would you do if the New York Times
reported your action and everyone was to read it.
• Think about how your decision will be remembered when you
are gone.
• Did you consider any relevant cognitive biases/barriers?
• What decision would you come to based solely on character
considerations?
 THINK CREATIVELY ABOUT POTENTIAL
ACTIONS
• Be sure you have not been unnecessarily
forced into a corner
• You may have some choices or alternatives
that have not been considered
• If you have come up with solutions “a” and
“b,” try to brainstorm and come up with a “c”
solution that might satisfy the interests of the
primary parties involved in the situation.
 Approach to Ethical Dilemma
Approach

Assessm ent Planning Im plementation Evaluation

Am I involved Determ ine goals W ork tow ards Determ ine

of treatm ent a m utually w hether desired
acceptable decision outcom es have been
reached

Collect Identify Use of Re-evaluate as necessary

the facts Decision-M akers discussion and
negotiation

W hat Values are in conflict List and

Rank the options
Ethical Decision Making Process
• Describe the problem
• Gather the facts
• Clarify values
• Note reactions
• Identify ethical Principles
• Clarify legal rules
• Explore options and alternatives
• Decide on a recommendation
• Develop an action plan
• Evaluate the plan
 Case #1
Patient is an 89 year old male admitted with
Hyperkalemia, ESRD, HTN, and Bladder Cancer.
Patient’s past medical history includes recurrent
bladder carcinoma, CVA, hernia repair and
hemodyalisis. Patient was admitted due to weakness
and 2 weeks of diarrhea for which he had refused to
be dialyzed for 7 days.
Patient lives at home with wife and daughter who
are both his healthcare surrogates. Based on
patient’s poor prognosis, oncologist had
recommended on previous admissions that patient
be made Hospice Care with comfort measures.
 Case #1 Cont.
Daughter and wife have refused Hospice care and
want patient to be dialyzed and continue
aggressive treatment to include full resuscitation
if cardiopulmonary arrest. Daughter and wife
have requested all physicians to refrain from
speaking to patient about his prognosis.
At this time all physicians have followed daughter
and wife’s request not let patient know that his
cancer has returned, except for the “new”
attending physician.
 Is there an Ethical dilemma?

• Autonomy?
• Nonmaleficence?
• Beneficence?
• Justice?
• Fidelity?
• Confidentiality?
• Veracity?
• Accountability?
 What would you do?
• Tell “new” physician to get on board with
the rest of the healthcare providers in
following the wife and daughter’s request…
• Tell the patient that his wife and daughter
are keeping information from him…
• Do nothing…
• Call for an ethics consult?
 Ethical Decision Making Process
• Describe the problem
• Gather the facts
• Clarify values
• Note reactions
• Identify ethical Principles
• Clarify legal rules
• Explore options and alternatives
• Decide on a recommendation
• Develop an action plan
• Evaluate the plan
 Resolution
• Ethics spoke with Attending physician and plan was to
speak first with daughter and wife regarding their role as
health care surrogates.
• Attending physician, healthcare team, and ethics would
then meet with patient and inquire if he wanted
information regarding his prognosis and/or medical care.
• After speaking with daughter, wife, and patient
individually and obtaining a clearer understanding of the
patient’s wishes, and the clarification of the healthcare
surrogates role, a family conference would be
scheduled with health care team and family to
summarize the findings…
 Resolution
• Things never go as you plan them…
• Daughter refused to have wife speak with
the team
• Daughter wanted to be part of the
conversation when attending spoke to her
father to inquire if he wanted information or
not…
• Attending agreed to let daughter be present
during the conversation (mistake)
 Case # 2
88 year old male with extensive medical history including end
stage Parkinson's disease. He was admitted due to pneumonia
and was intubated and now is in Intensive care unit. Patient’s
wife was identified as proxy since patient had never completed
an Advance Directive or had a Living Will.
2 weeks have passed and patient has been unable to be weaned
from ventilator.
Wife continues to indicate she wants to take patient home on the
ventilator…
Attending physician did not feel that wife’s request to take patient
home were realistic nor did he feel patient would have “a good
quality of life.”
His recommendations were Comfort Measure/Withdraw of life
support.
 Case # 2 Continued
Palliative Care is involved and many family
conferences have been held. Wife refuses to
make patient a Do Not Resuscitate, or sign any
type of withdrawal papers. She wants “full care”
She continues to verbalize she wants to take patient
home.
Wife had full time 24 hour care team at home taking
care of patient and she wants to take him home.
Ethics consult is called by attending physician….
 What would you do?
• Try to convince wife that a DNR would be
the best for the patient in his condition…
• Speak to physician to find out what he
plans to do next…
• Call for an ethics consult
 Ethical Decision Making Process

• Describe the problem

• Gather the facts
• Clarify values
• Note reactions
• Identify ethical Principles
• Clarify legal rules
• Explore options and alternatives
• Decide on a recommendation
• Develop an action plan
• Evaluate the plan
 Resolution
Palliative Care and ethics consultant met with wife and she
understood that if he went home, he would have to have a
tracheotomy. Recommendations from team was to arrange
Respiratory department to show caregivers and wife how
to take care of patient once he was at home with
tracheotomy.
Wife agrees to tracheotomy and a consult is requested.
Wife was also informed of him having to go to a skilled
nursing facility first and then after he was stronger would
be able to go home.
Patient was trached and discharge to skilled nursing facility
for rehab.
 Case #3
54 year old male - history of previous subdural hematoma, HTN, and
atrial fibrillation. Patient aspirated and coded. He is in intensive
care unit on ventilator and Dopamine for hemodynamic stability.
Attempts at weaning have been unsuccessful…wife (healthcare
surrogate) signed consent for tracheotomy in order for patient to be
weaned off ventilator as recommended by pulmonologist…
On the same day wife signed consent for tracheotomy, Primary Care
Physicians during rounds feels that his prognosis is poor, and his
recommendation for plan of care is to have patient made CMO and
eventually withdrawal of life support should be initiated, he did
not agree with pulmonologist recommendations…
Pulmonologist does not agree with current plan to make patient CMO
and withdrawal and wants to continue therapy…”he can improve,
give him time”.
 Case #3 Cont.
Pulmonologist contacts wife regarding the scheduling of the
tracheotomy, and is surprised to find out that she has signed
papers for Comfort Measures Only & withdrawal of
ventilator…
Family is now confused with conflicting goals of care…wife has
agreed to CMO and withdrawal of vent after speaking with
attending but is still not sure she is doing the right thing…she
would like to give time but “how long?”
Staff is torn between wife’s decision and her verbalization of
“confusion” and physician’s recommendations and conflicting
opinions by pulmonologist and attending physician…
Pulmonologists calls for ethics consult…patient is not
withdrawn awaiting ethics recommendations…
 What would you do?
• Tell wife attending is right and she should sign the
CMO papers…
• Tell wife she should get a pulmonologists second
opinion…
• Call Risk Management because of the conflict
between the attending and pulmonary doctor…
• Call attending and tell him wife is confused…
• Do NOTHING!
** Ethics Consult was requested by pulmonologist…
Ethical Decision Making Process
• Describe the problem
• Gather the facts
• Clarify values
• Note reactions
• Identify ethical Principles
• Clarify legal rules
• Explore options and alternatives
• Decide on a recommendation
• Develop an action plan
• Evaluate the plan
 Resolution
• Social Work and ethics chair spoke individually to attending
and pulmonologist to clarify goals of care and prognosis.
• Social Work and ethics consultant spoke with patient's wife
and she verbalized her confusion but had agreed to sign
CMO and Withdrawal of life support at the time because
she didn’t really understand what that meant…
• Wife wanted to give her husband a chance to be weaned off
ventilator and she rescinded the CMO and Withdrawal of
Life Support forms
• Patient had the scheduled trache done the following day
• Patient was transferred to vent floor and was transferred to
long term care facility for rehab…