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ETHICS and ETHICAL ISSUES

Author: Alene Burke RN, MSN
2 Contact Hours

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DESCRIPTION:

This course will provide the learner with an overview of various ethical principles; the evolution of ethical thought throughout history; ethics in healthcare and nursing; ethical dilemmas and ways to resolve them; commonly occurring and most recently encountered ethical issues in healthcare; and available resources that aid in the facilitation of ethical decision-making.

OBJECTIVES:

1. Define and detail various ethical principles and concepts, such as autonomy, beneficence, nonmaleficence, and justice.
2. Relate the historical and current evolution of ethical thought including milestones, such as the Hippocratic oath and the American Nurses Association's Code of Ethics.
3. Articulate ways in which ethical dilemmas can be resolved and methods of ethical decision-making.
4. Detail some commonly occurring ethical issues and resources, including human resources that can be used to make ethical decisions.

INTRODUCTION

Ethics and ethical practice has, and continues to remain, one of the most important paramount decision-making frameworks in healthcare as well as in other professions. Many professions and professionals are often in a position where they influence the lives of others. This position makes it necessary for them to accept the responsibility of acting ethically and in the interest of those they serve. Ethically, we are held accountable for our acts of omission and commission.

Professions have ethical codes in order to thoroughly, and as parsimoniously as possible, address all possible ethical concerns in the profession. Ethical codes are formal statements about commitments to the good. They contain values and guide the practice(s) of those in the profession or business area.

Accountants, attorneys, real estate brokers, and government employees have codes of ethics that they must adhere to. Accountants are held accountable for honesty and honest accounting practices; real estate brokers are held accountable for disclosures regarding problems and potential problems, such as asbestos, lead and sink hole risks; attorneys are ethically bound to maintain confidentiality and privileged communication regarding some matters; and government employees are ethically bound to avoid any conflicts of interest. Recently, corporate ethics has become a national focus of attention, especially after the Enron Corporation collapse and their faulty accounting systems.

The ultimate purpose of ethical codes in the healthcare industry is to protect the rights and safety of the healthcare consumer. Healthcare professionals must act ethically and adhere to their own professional codes of ethics. (National Council of State Boards of Nursing, 1996)

ETHICS: BASIC PRINCIPLES AND CONCEPTS

Ethics is defined as "the discipline dealing with what is good and bad and with moral duty and obligation; a set of moral principles or values; a theory or system of moral values; the principles of conduct governing an individual or a group <professional ethics>; a guiding philosophy" (Merriam-Webster,2001).

Ethics is a body of knowledge containing values that are held by individuals of groups. Ethics and ethical codes in healthcare reflect four basic ethical principles, or underlying themes, that serve to organize the body of medical ethics and medical ethical decision-making.

These four ethical principles are:

• Autonomy,
• Beneficence,
• Nonmaleficence, and
• Justice.

Autonomy is "the quality or state of being self-governing; especially : the right of self-government; self-directing freedom and especially moral independence; a self-governing state" (Merriam-Webster, 2001).

Beneficence is defined as "the quality or state of being beneficent" (Merriam-Webster, 2001).

Nonmaleficence is best described as doing no harm. The Hippocratic Oath is an excellent example of how, historically, ethics and ethical principles have been in the healthcare profession throughout the ages. The Hippocratic Oath can be read below in Table 1.

Justice is defined as "the maintenance or administration of what is just especially by the impartial adjustment of conflicting claims or the assignment of merited rewards or punishments; the administration of law; especially: the establishment or determination of rights according to the rules of law or equity; the quality of being just, impartial, or fair; the principle or ideal of just dealing or right action; conformity to this principle or ideal; the quality of conforming to law; conformity to truth, fact, or reason; correctness "(Merriam-Webster,2001).

Autonomy

The word autonomy is derived from the Greek word for self-rule. In reference to healthcare, autonomy is strongly linked to the client's right to decision-making and self-determination. All competent adults have the basic freedom to choose and make choices.

Patients and residents have a right to informed consent and informed refusal. They have the basic right to autonomous, knowledgeable decision-making and the ability to make choices, whether or not the healthcare provider(s) agrees with them or not.

Adults have the right to make decisions when they are of majority age, that is, at least 18 years of age, and they are deemed mentally competent to do so. Minors, on the other hand, are not legally able to make a decision about what care they will or not receive until they reach the age of 18 or they become a legally emancipated minor. Parents generally make legal decisions for minors. In some cases, a court appointed guardian makes these decisions, in the absence of a parent.

The adult consumer of healthcare services, or their surrogate, proxy, decision maker, has the right to consent to care and they also have the right to refuse any aspect of care or a treatment. These autonomous decisions are based on the individual's own unique values and beliefs; they are not based on what the healthcare provider feels is best for them. Self determination and autonomous decision-making must be ethically upheld by all healthcare professionals at all times.

Beneficence

Simply stated, beneficence is doing good. Beneficence is doing the ethically correct thing. It reflects an individual's intentional acts, not errors and mistakes. Beneficence aims to promote the well being of others, not self. These intentional acts take into serious consideration the welfare of others. It is the welfare of others that is of greatest importance.

Beneficence challenges and ethical dilemmas in healthcare occur when it is not totally clear about what is truly good for a particular patient. Patient and resident needs are generally complex and approaches to care are numerous and varied. Many dilemmas arise because of these complexities and other factors.

The multidisciplinary healthcare team sometimes has difficulty arriving at a plan of care that is best for the patient and even then, not all members of the team may be in agreement about what course of treatment or care is best. Additionally, the autonomous decisions of the patient may make the "best" treatment options not feasible because the patient, resident or surrogate, proxy, decision maker has expressed the fact that they do not want a particular treatment or intervention. Lastly, the team and patient or resident may collectively agree to what is best, but this option is not available or accessible to them and/or the option may not be legally permissible. For example, euthanasia is not legally permitted in our country. Any patient requests for euthanasia, therefore, cannot be supported because it is illegal. The healthcare team cannot agree to, or support, this option despite their own personal beliefs that euthanasia should be a legally acceptable and that this is the "best" option, especially when a patient or resident is using their right to self determination by expressing a desire for it.

Nonmaleficence

Nonmaleficence literally means, "do not harm". Maleficence is defined as "doing harm". Nonmaleficence and beneficence are closely related, particularly in healthcare ethics, because many treatments and procedures have both benefits (beneficence) and risks for harm. Some of these risks can cause patient harm and pain (maleficence).

For example, a client under our care may choose to have parenteral nutrition to correct a nutritional deficit. Prior to consenting, the individual was correctly and completely informed about parenteral nutrition, its benefits and its risks, including those associated with infection. Alternatives to parenteral nutrition were also discussed with the patient or proxy decision maker, as appropriate. If this patient chooses to have the parenteral nutrition and gets an infection as a result of it (maleficence), it is not considered unethical because the patient autonomously decided to have the parenteral nutrition after they were advised of the risks associated with this treatment and because the harm, or infection, was not done intentionally by the nurses and other healthcare professionals.

Justice

The principle of justice entails fairness, impartiality, and justness. Challenges in the area of justice are numerous in the healthcare industry, particularly because fair and impartial access to care is sometimes not possible due to the constraints associated with healthcare dollars and the allocation of limited resources. These kinds situations are generally highly complex and difficult to resolve using justice alone as the ethical framework for decision-making.

Other healthcare situations, however, are easily addressed in terms of the principle of justice. Providing the same level of care and the same level of quality for all those in our care, without discrimination, is straightforward and quite simple to ethically accomplish.

ETHICS IN HEALTHCARE AND NURSING: HISTORY AND CURRENT STATE

Historically, the first documented sign of ethics in healthcare was the Hippocratic Oath that was discussed above in the context of nonmaleficence. Florence Nightingale continued the development of ethics for nurses as she promoted ethics throughout her practice and within the schools of nursing that she was instrumental in running. The need for ethics and ethical practice in nursing and healthcare continues from these early beginnings to the current day.

At the current time, the International Council of Nurses' Code of Ethics for Nurses, on a global scale, and the American Nurses' Association Code of Ethics, on the national level, ethically drive the majority of nurses and the bulk of nursing practice in our nation. There are, however, other ethical codes that address subspecialties with the profession, for example, nursing research.

International Council of Nurses

The International Council of Nurses (ICN) initially composed an international code for nurses throughout the world in 1953. Their most recent Code of Ethics for Nurses (2000) is organized around four elements, as follows:

1. nurses and people,
2. nurses and practice,
3. nurses and coworkers and
4. nurses and the profession.

The nurses and people element addresses basic client rights, confidentiality, and the need to uphold these rights, as well as the values and customs of the healthcare consumer.

The nurses and practice element includes guidance regarding competency, education and continuing education, personal health and the need for nursing judgment in respect to accepting and delegating the responsibility of client care.

The third element, nurses and coworkers, underscores the need for cooperation and collaboration as well as the need to take immediate action when a nurse believes that the actions of others jeopardize quality of care.

Finally, the fourth element, nurses and the profession, relates to the need for nurses to abide by their standards of practice and to actively participate in the expansion of their unique body of knowledge.(International Council of Nurses, 2000).

American Nurses Association (ANA)

The most recent American Nurses Association Code of Ethics was published in 2001. Some of the same elements included in the International Council of Nurses' ethical code are also found in the ANA's ethical code. The Code, however, is organized around nine provisions as below:

The nine provisions address:

1. dignity and the uniqueness of every individual. Respect, compassion and the provision of care to all without any discrimination is emphasized
2. the need for nurses to accept their responsibility in making a commitment to the client. The client is defined in this ethical code as an individual, group and/or community.
3. advocacy. The need for nurses and the nursing profession to protect the rights, health and safety of the client is underscored in this provision.
4. accountability and responsibility for one's own practice. This provision holds the nurse responsible and accountable for their own practice. Additionally, the nurse is held accountable for the delegation of aspects of care to others, According to the American Nurses Association Code of Ethics, delegation must be done using sound professional judgment and taking into consideration what is best for the client(s) receiving nursing care.
5. responsibilities to one's self-safety, integrity, competence and growth, personal and professional are the responsibilities of the nurse.
6. the need for nurses to act, on an individual and collective basis, to establish, maintain and improve conditions of employment and the place of employment in order to facilitate the provision of safe, quality care.
7. contributions that nurses must make in terms of clinical practice, administration and education in order to advance the profession of nursing.
8. collaboration with the public and other healthcare professionals in order to best meet the needs of the community on a local, national and international level.
9. the role of the nursing profession in terms of maintaining its own integrity and practice, as well as the responsibility of the profession and its members to shape public policy and articulate nursing values. (American Nurses Association, 2001)

ETHICAL DILEMMAS

An ethical dilemma arises when two or more of the four (autonomy, beneficence, nonmaleficence, and justice) ethical principles are in conflict with one other. For example, when what is good is not justly and fairly distributed or when autonomy is in conflict with beneficence.

Ethical dilemmas disrupt internal and external harmony and homeostasis. They are uncomfortable and often a source of disagreement and debate among members of the healthcare team. For example, an ethical dilemma relating to who gets and who does not get a particular treatment or an organ, can be a source of great consternation and frustration. Allocating limited healthcare resources is an omnipresent challenge in our industry.

Ethical dilemmas, although challenging, can be resolved. Ethical dilemmas are best resolved on a case-by-case basis within the context of the unique patient and their unique needs and by using the four basic ethical principles for analysis and decision-making.

The resolution of ethical dilemmas is also best accomplished by a group, rather than one individual. Collective analysis and decision making promotes diverse thinking and often a decision that can be ethically and comfortably accepted by all of those involved in the process.

ETHICS COMMITTEES

Most healthcare facilities now have ethics committees to address ethical dilemmas. Attend a meeting at your facility, especially if you have never attended one before. Ethics committees typically consist of a diverse group of healthcare professionals from different disciplines. Most often there will be representatives from medicine, nursing, pharmacy and nutritional services. Many also have an administrator, a chaplain and a healthcare consumer as members. An ethicist consultant is sometimes added to the group composition when the group is having difficulty resolving a dilemma without the help of an expert ethicist to consult with.

Ethics Committee policies and procedures vary from facility to facility, however, ones that make provisions for the following are the most helpful.

• Ethics committee members should be educated about ways to analyze ethical dilemmas and about sound ethical decision-making. Ethical dilemmas should be analyzed with a systematic exploration of ethical values according to their level of importance until the two or more ethical principles that are in conflict with each other become balanced. After analysis a consensus should be obtained in terms of the decision making process.
• Staff should have formal and informal ways to articulate their ethical concerns. Ethical dilemmas occur at the bedside not in administrative offices. Committees that are not responsive to all levels of staff and their concerns cannot be effective in fulfilling their roles and responsibilities.
• Staff should be able to expect a decision from the ethics committee in a timely manner. Ethical dilemmas are a source of stress for individuals and groups. Often, they are divisive. They also threaten the safety and well being of the patient. Staff should be able to expect that an ethical decision is made in a prompt and timely manner so that the dilemma can be resolved and patient care decisions can then be made and carried out without conflict. Additionally, it is usually helpful to have the staff member attend the meeting during which their dilemma is analyzed and resolved. They will be able to add to the discussion in terms of the unique situation and will also benefit from the learning and personal growth they acquire as a result of their participation.
• Ethics committees should educate members of their facility about ethics, ethical dilemmas, ethical decision-making, the role of their ethics committee and how to communicate an ethical concern or dilemma.

Ethics committees are an excellent resource for nurses and all other healthcare professionals.

COMMON ETHICAL ISSUES

Inadequate Staffing

Inadequate staffing and unsafe staffing levels are a matter of grave concern. Some states, for example California and Florida, now have minimum staffing laws to prevent the problems associated with inadequate and unsafe staffing. Although these laws have somewhat helped, they have not eliminated the problem altogether.

What should a nurse, or other healthcare provider, do when they believe that staffing is not adequate enough to safely and effectively meet the needs of the patients that they are caring for? Should they refuse the assignment? Should the nurse accept the assignment but pursue the matter in a formal and prompt manner? Should they just ignore the problem and do the best they can do?

The answers to these questions are not simple and easy. Inadequate staffing is a complex problem without simple solutions. Unsafe staffing can be a sporadic and rare occurrence, one that results from someone calling in sick or it can be an ongoing problem with no apparent efforts underway to correct it.

Ethically, the nurse must address inadequate staffing in order to protect the patients and their rights to safety, freedom from harm and quality care. Ignoring the problem not only places the nurse in a position of legal liability, it is also not ethical. Ethically, the nurse must uphold the principles of beneficence and nonmaleficence. The nurse's duty to promote the well being of others (beneficence) is not being fulfilled and the nurse's duty to do no harm (nonmaleficence) is also not being fulfilled.

Patients suffer harm and a lack of the care they are entitled to as a result of inadequate and unsafe staffing levels. Additionally, according to the American Nurses Association Code of Ethics nurses must act, on an individual and collective basis, in order to establish, maintain and improve workplace conditions that promote the provision of safe, quality care.

Although inadequate staffing is not an ethical dilemma with two or more ethical principles in conflict, it is a frequently occurring ethical issue because one or more of the four principles of ethics are not upheld. Nurses, and other healthcare providers, must report staffing concerns to their supervisor and then up the chain of command until the situation is rectified. Yes, it is true that your actions may lead to some repercussions, nonetheless, it is your ethical responsibility to do so.

Inappropriate Doctor's Orders

Inappropriate doctor's orders are also a frequently occurring ethical issue. What should a nurse, or other healthcare professional, do when they believe that a doctor's order is not appropriate for the patient? Should they just ignore the order? Should they just carry out the order because the doctor ordered it?

Healthcare providers, using profession judgment, should know what doctors' orders are and are not appropriate based on the current condition of the patient. They must question an order when they suspect that it is inappropriate. A questionable order must never be carried out until it is clarified and deemed appropriate by the person carrying it out. To carry out an inappropriate order jeopardizes the ethical principles of beneficence and nonmaleficence. Similar to unsafe staffing levels, this is an ethical issue rather than an ethical dilemma with two or more competing ethical principles. To carry out an inappropriate order is simply unethical.

The first thing that a nurse, or another professional, must do when they are given an order to do something that is inappropriate, illegal or unethical is to NOT follow the order. Communicate with the person giving the order, and document that conversation as well as your rationale for not following the order. Clearly communicate, and document the patient's current condition and why the order is not consistent with the patient's current condition. Communicate with your supervisor and follow further up the chain of command, or the channel of communication, until the inappropriate order is discontinued or it becomes apparent to you that it is indeed appropriate and necessary. To do otherwise is to jeopardize the well being of the patient and perhaps cause harm (maleficence). Yes, your questioning actions and your refusal to follow the order may lead to some repercussions, nonetheless, there are no other options. It is your professional, ethical responsibility to do good and to do no harm.

Euthanasia and Physician Assisted Suicide

Euthanasia and physician assisted suicide are commonly occurring and recent emergent ethical issues, ones with a tremendous amount of lively ethical debate on the international, national and local frontier. These issues are highly complex with religious, legal and cultural implications.

Those that support euthanasia and physician assisted suicide feel that quality of life and the right of an individual to self determination must be addressed with these alternatives, especially when the availability of so many life saving and life supporting interventions tend to prolong a life with little or no quality and when a person chooses to die rather than live. Those who argue against euthanasia and physician assisted suicide believe that they are immoral and equivalent to murder. They also argue that euthanasia and physician assisted suicide can lead to the eradication of people viewed by society as not having a satisfactory quality of life. For example, some believe that euthanasia can lead to the elimination of developmentally disabled people once it is legally acceptable.

Voluntary euthanasia can be defined as the intentional act of ending a life at the request of a competent person who wishes to die. Involuntary euthanasia is defined as the intentional ending of someone's life without the request of a competent person. Euthanasia is also referred to as "mercy killing".

Physician assisted suicide is a similar concept, but it is slightly different. Physician assisted suicide is defined as a person ending their own life with the assistance of a physician. Typically, this assistance consists of the provision of medications, which the person can use to end their life when they decide to do so. Physician assisted suicide involves a physician making the death available but they do not serve as the direct agent, whereas, there is a direct agent, such as a physician or a nurse, that is involved with voluntary and involuntary euthanasia.

In 1994, the American Nurses Association (ANA) published a position paper entitled "Ethics and Human Rights Position Statements: Active Euthanasia, in which it addressed the issue of active euthanasia. The ANA does not consider voluntary or involuntary euthanasia ethical.

Euthanasia is also not permitted by law in the United States even if this action can be viewed as compassionate and supportive of the patient's wishes, either explicit or implicit. It is not legal.

The American Nurses Association (ANA) has, however, addressed some commonly occurring issues of ethical concern at the end of life, including the need to provide comfort even when comfort measures result in the cessation of some basic bodily functions, such as respiration. They also ethically support the cessation of hydration and nutrition, and the withdrawal of and withholding of resuscitation and other life sustaining measures, when chosen by the patient or surrogate decision maker in the absence of the patient's wishes.

The ANA, in support of the patient's need for comfort at the end of life, does encourage the implementation of pain management regimens even if these interventions hasten death. However, such interventions cannot be employed for the sole purpose of ending a life. (American Nurses Association, 1994; American Nurses Association, 2001).

"A nurse's role with regard to a terminally ill patient encompasses promotion of comfort and an optimal dying experience and extends through the continuum of life through death. Careful assessment and management of pain should be the principal goal of a palliative care plan." (American Nurses Association, 2001)

The ANA position statement, Promotion of Comfort and Relief of Pain in Dying Patients (2001), explores the issue of pain control in the terminally ill. The statement makes two important points:

• "Pain relief and the promotion of comfort as primary acts are hallmarks of professional nursing practice.
• The possibility of hastening death through the acts of promoting comfort and alleviating pain is a possible consequence of the primary act and is therefore ethically justified." (American Nurses Association, 2001)

* Many factors in a patient's personal profile should be considered when administering potentially lethal doses of medication. These include the existence of a living will, cultural background, family influences, and the patient's desires. The appropriate consideration of these factors necessitates reciprocal relationships among physician, nurse, patient (if able), and family, in which there is open discussion of all parties' concerns and needs.

Pain relief, facilitation of comfort, and an optimal dying experience must be differentiated from two unethical means of ending life, active euthanasia and assisted suicide. These acts stand in conflict with the ANA's Code for Nurses with Interpretive Statements, 1985, which serves as the main ethical resource for the guidance of nursing actions." (American Nurses Association, 2001)

"The Pain Relief Promotion Act (H.R. 2260), introduced in Congress in 1999, includes a troubling provision allowing the Drug Enforcement Agency to investigate the intentions of health care professionals who prescribe medication. The ANA opposes this legislation, believing it would create a barrier to effective palliative care and prevent patients from receiving end-of-life treatment. The ANA has urged Congress to vote against the proposed legislation and to focus more attention on federal support for pain management and palliative care." (American Nurses Association, 2001).

ETHICAL RESOURCES

Websites

The American Society for Bioethics and Humanities www.asbh.org/

American Society of Law, Medicine & Ethics www.asbh.org/

Center for Biomedical Ethics at Case Western Reserve University www.cwru.edu/med/bioethics/bioethics.htm

Center for Biomedical Ethics at Stanford University scbe.stanford.edu/

Center for Ethics and Humanities in the Life Sciences at Michigan State University www.bioethics.msu.edu/

Center for Ethics in Health Care (Oregon Health Sciences University) www.ohsu.edu/ethics/

Center for Medical Ethics and Health Policy at Baylor College www.bcm.edu/ethics/

Do No Harm; The Coalition of Americans for Research Ethics www.stemcellresearch.org

International Bioethics Committee (part of UNESCO) portal.unesco.org/shs/en/ev.php-URL_ID=1372&URL_DO=DO_TOPIC&URL_SECTION=201.html

Kennedy Institute of Ethics kennedyinstitute.georgetown.edu/site/index.htm

National Bioethics Advisory Commission (U.S.) www.bioethics.gov

National Catholic Bioethics Center (U.S.) www.bioethics.gov

Books and Publications

Code of Ethics for Nurses With Interpretive Statements by American Nurses Association

Case Studies in Nursing Ethics by Sara T. Fry, Robert M. Veatch

Nursing Ethics : Across the Curriculum and Into Practice by Janie Butts and Karen Rich

Ethics And Issues In Contemporary Nursing by Margaret A. Burkhardt and Alvita K. Nathaniel

Nursing Ethics through the Life Span (4th Edition) by Elsie Bandman and Bertram Bandman

Sensitive Judgment : Nursing, Moral Philosophy and the Ethics of Care by P. Nortvedt

Concepts and Cases in Nursing Ethics (2nd Edition) by Anne Moorhouse and Michael Yeo (Editors)

Ethics in Nursing Practice: A Guide to Ethical Decision Making by Sara T. Fry and Megan-Jane Johnstone

Nursing Ethics: Communities in Dialogues by Rose Mary Volbrecht

Nursing Concepts: Ethics & Conflicts by Kathleen Ouimet Perrin, et al

REFERENCES

American Nurses Association. (1994). "Ethics and Human Rights Position Statements: Active Euthanasia". nursingworld.org/readroom/position/ethics/prteteuth.htm

American Nurses Association (2001). "Code of Ethics for Nurses with Interpretive Statements", Washington, D.C.: American Nurses Publishing. nursingworld.org/ethics/chcode.htm

American Nurses Association (2001). "Dying for Relief: When Pain Relief Could Result in Death" . www.nursingworld.org/AJN/2001/feb/Wrights.htm

Howard University School of Medicine Program in Clinical Ethics (2005). "Healthcare Ethics Glossary". www.med.howard.edu/ethics/handouts/health_care_ethics_glossary.htm

International Council of Nurses (2000). "Code of Ethics for Nurses". www.icn.ch/icncode.pdf

National Council of State Boards of Nursing (1996). "Public Protection or Professional Self-Preservation? The Purpose of Regulation." Chicago, IL: NCSBN. www.ncsbn.org/resources/complimentary_ncsbn_publicpro.asp.

Scarborough, John (2005). "Hippocrates." World Book Online Reference Center. 2005. World Book, Inc. www.aolsvc.worldbook.aol.com/wb/Art

Contact Hours: 2
Price: $15.00
Course Title: ETHICS and ETHICAL ISSUES
Course Number: 20-51421

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