What do I do now? Ethical dilemmas in nursing and health care.
Each of us has a moral "lens" through which we view the world. This sense of morality gives us our sense of what is right and wrong. We make choices every day based on our moral views-telling the truth, refraining from shoplifting, helping a colleague who requests assistance. While these behaviors do not represent true dilemmas, they do require that we make choices. Our choices are based on what we believe to be right, based on our upbringing, our culture, our spiritual perspectives, our peer group values, and other factors that are unique to each of us.
Challenges arise when those around us have different moral views. While we are each entitled to our own views and preferences, we do not have the right to impose those views on others. It is important to recognize that people have the right to make choices, even though they may not be the choices we believe we would make for ourselves. In those cases, it's not so much a matter of "right" vs. "wrong," but different people's perceptions about what is "right."
No matter what our personal moral views might be, employers establish policies regarding appropriate behavior in the workplace. These expectations are considered our "organizational ethics." This study will briefly address issues related to organizational ethics, including standards provided in the Code of Ethics for Nurses (ANA, 2010).
Clinical ethics, on the other hand, relates to dilemmas that arise when difficult clinical choices must be made. While many ethical dilemmas arise related to beginning or end-of-life issues, ethical dilemmas can and do occur with patients of any age and in any part of the healthcare system. Numerous examples of ethical dilemmas will be presented in this study, following a discussion of the theoretical frameworks for understanding ethical decision making. The role of the registered nurse in supporting patients and families in addressing ethical dilemmas will be emphasized.
Expectations about the "right" behaviors for employees in the work setting are referred to as "organizational ethics." Similarly, professions have standards expected of their members- these are referred to as "professional ethics." Professional ethics include expectations related to the work environment as well as those related to roles of members of that profession.
A code of ethics for nursing in the United States was first developed in 1893 and is still familiar to many nurses as the "Nightingale Pledge" (ANA, 2010). The American Nurses Association first adopted a code of ethics in 1950, and has made subsequent revisions to reflect contemporary changes. While the current Code was published by ANA in 2001, a 2010 Guide to the Code of Ethics for Nurses provides support for integration of these ethical standards in today's healthcare practice. As stated in the 2010 document (p. xviii), "The Code for Nurses reflects both constancy and change-constancy in the identification of the ethical virtues, values, ideals, and norms of the profession, and change in relation to both the interpretation of these virtues, values, ideals, and norms, and the growth of the profession itself."
The ANA Code of Ethics with Interpretive Statements (2001) consists of nine focal areas, displayed in Table 1. In this book, each of the provisions is identified and explained. The 2010 Guide to the Code of Ethics for Nurses continues the explanations of each of these provisions, with contemporary examples, case studies, and supportive references. Collectively, these documents represent the view of nursing's professional association on expected behaviors of nurses as professionals-to their patients, their colleagues, their employers, themselves, their communities, and the profession itself.
There are numerous other documents and resources that explain and support the expected organizational ethics of the practicing nurse. Some of these include facility human resources polices, regulatory requirements issued by state boards of nursing, and local, state, and federal laws which nurses and all other citizens are expected to follow. Failure to follow facility policy may result in disciplinary action by an employer.
Different laws/rules regulating the practice of nursing in each state specify expected behaviors of nurses. Failure to follow board of nursing requirements can result in disciplinary action on a nursing license. Examples of behavioral expectations of nurses cited in the board's Administrative Code include, among others:
* Maintaining competence
* Protecting privacy and confidentiality
* Sharing appropriately with others to provide safe care
* Respecting dignity of each patient
* Maintaining professional boundaries
* Respect and safeguard the property of the patient
* Not falsifying documents
* Using unsafe judgment, technical skills, or inappropriate interpersonal behaviors in providing nursing care.
* Delivering care without prejudice
* Protection of clients from exploitation, abuse, and/or neglect
A nurse is expected to be familiar with facility policy, applicable laws/rules, and other requirements for appropriate behavior in the work environment. Examples include employer expectations regarding appropriate behavior and attire at work, requirements for maintaining privacy and confidentiality of protected patient information, and procedures for reporting errors. Increasingly, facilities are also developing policies around such issues as use of social media by healthcare providers and whether or not providers can have visible tattoos and other "body art" in the work environment. Some facilities have now established policies stating that employees may not be smokers. While one might make the argument that the employer does not have the right to dictate employee behaviors outside of the work environment, the employer's perspective is that the risks to the employer and other employees outweigh the benefits to the one individual-employer risks are increased in terms of insurance costs, sick days, and loss of productivity.
Federal, state, and local laws are also issues that fit within the framework of organizational ethics. One example is that of "intellectual property"- if an employee develops a patient teaching video or produces a manual detailing the work of the organization, for example, that "product" is considered to be the property of the employer. The employee cannot take that product to be used in another organization, nor can he/she market or sell the product as his/her own.
Unfortunately, one issue that occurs in the health care workplace is fraudulent documentation. Regulatory boards typically have rules about accurate documentation, so purposefully committing fraud in the documentation process is a violation that can lead to disciplinary action on a nursing license. Additionally, this could lead to the nurse being charged with insurance fraud in court. Ethical behavior requires that the nurse document properly, including appropriate corrections of inadvertent errors.
The nurse is accountable to know facility policies and relevant laws/rules. As the old adage says, "Ignorance of the law is not an excuse"! Questions can be directed to a facility's human resources office or to the agency issuing the relevant law or standard.
Employers often have "opt-out" options for nurses whose personal moral views are not compatible with participation in a particular aspect of patient care. While there is some variability in individual policies, the general focus is that the nurse has the opportunity to advise his/her manager that he/she chooses not to participate in a particular procedure or care due to a personal moral conflict. Presuming someone else is available to provide that care, the nurse is able to accept an alternative assignment. Employers do require, though, that someone be available to provide the care needed by the patient.
Ethical behavior also relates to continuing education. Learning activities in which you participate must be free of bias and be based on best available evidence (ANCC, 2011). As a learner, you have a right to expect learning activities that truly focus on learning and not on product promotion. The nurse planner for the activity is accountable for ensuring that people who have the ability to control content in a continuing education activity, such as planning committee members, faculty, and authors, have disclosed any relevant conflict of interest and determining that the conflict will not impact the integrity of the learning activity. Likewise, those conflicts of interest must be disclosed to learners, so you will know that appropriate vetting processes have been implemented.
Another example of organizational ethics in the work environment is use of institutional review boards. When someone proposes to do a research project that involves human subjects, it is required that the planned research activities be analyzed and approved by the facility's institutional review board. Things such as informed consent for prospective participants and a person's ability to voluntarily withdraw from the study at any time are reviewed. This provides evidence of the integrity of the research project in relation to how human subjects are used.
In the previous situations, there are clearly identified expectations regarding how people are expected to behave in the work environment. Regardless of a person's moral views, there is a "right" way to behave at work. Failure to follow policies outlining an organization's ethics-based policies can result in termination of employment. Failure to follow regulatory statements related to appropriate, ethical treatment of patients can result in disciplinary action on a nurse's license. Failure to follow laws related to ethical behavior, such as protecting confidentiality and avoiding fraudulent documentation, can result in civil or criminal charges against the nurse.
Clinical ethics, on the other hand, does not provide a single point of reference for how people "should" behave. There are as many possible different "right" answers as there are people in any given clinical scenario. There are, instead, a variety of potential "right" options, each of which deserves to be explored with respect, consideration, and thoughtfulness. The role of the nurse in these situations is not to tell the patient and/or family what to do. Likewise the nurse is not expected to "take sides" or present arguments for or against a particular option. Rather, the role of the nurse, and of the healthcare team, is to listen, to encourage all parties to share their views, and to respectfully guide the process of analysis of options and their consequences. It is critical to remember that members of the healthcare team have the privilege of interacting with this patient and family during a particular moment in their lives. However, the outcomes of ethical decisions, because they are so closely tied with people's values, morals, religious beliefs, and other foundational aspects of life, will continue to resonate with these families for years after the particular clinical episode has ended. For this reason, thoughtful deliberation is encouraged, rather than quick decision-making and action.
Situations related to decision-making about issues that arise in the context of healthcare decision making are referred to under the heading of "clinical ethics" or bio-ethics. Stakeholders in clinical dilemmas may include patients, family members, nurses, physicians, other care providers, religious leaders, cultural group representatives, and others, depending on the particular case. Based on the earlier definition of personal moral views, it is important to remember that people come to these difficult healthcare decision points from different perspectives. Different people have different views on what is "right" to do in any particular situation.
As an example-presume that a 78 year old man falls off a ladder while cleaning gutters on his second story home. His wife hears him fall and finds him collapsed in the driveway, not breathing. He is treated by emergency medical personnel at the scene, intubated, and transported to the hospital. He is admitted to critical care, unconscious, with severe head trauma, internal injuries, and several broken bones.
Three days later, he remains comatose and on the ventilator. Two physicians have examined the patient and concurred that it is highly unlikely this gentleman will survive. The primary care provider meets with the family to discuss removal of the ventilator. His perception is that the "right" thing to do is remove the ventilator. The wife's perception is that the "right" thing to do is continue to provide all possible medical care with the goal of working toward recovery from this acute injury. The daughter's perception is that the "right" thing to do is wait at least one week to see if her father makes any progress toward recovery before making a definitive decision about the ventilator. All of these options are possibly "right"-there is no "wrong" choice. There are just different perspectives, depending on the frame of reference, clinical perspective, and personal moral views of each "player" in this scenario.
Interestingly, the focus on addressing ethical dilemmas in the healthcare setting is a relatively new phenomenon. Onset of the Nuremburg trials in the late 1940's, when the atrocities committed against human beings during World War II became known to the public, is often heralded as the beginning of the "modern era" of ethics. Since that time, there have been standards developed for such things as clinical trials, use of human subjects for research, and other activities designed to protect individuals from mistreatment.
Up until the past 5-6 decades, there was not much need for ethics committees or ethical deliberations about healthcare decisions. Patients who had conditions that did not respond to the treatments available in that day simply died. Women who could not get pregnant chose to adopt or remain childless. With the advent of modern medicine, new medical and surgical treatment options and advanced technological support for clinical functions have changed people's previous views of what could and could not be done. Now, there is almost an expectation of a medical miracle for every health problem. This often creates distorted perceptions on the part of both patients and providers about what is "right" to do in any given situation. The study of clinical ethics focuses on how these decisions are made, and how the healthcare team supports patients and families in addressing ethical dilemmas.
There are a number of theoretical frameworks that guide thinking around ethical dilemmas in the clinical setting. Some of these are offered mostly from the historical perspective; others have significant impact on how decisions are currently made. Each will be described briefly, and then more focus will be placed on those theories most commonly used in today's clinical practice.
Virtue ethics is based on what people believe to be required of them in order to be virtuous, or excellent in moral reasoning and behavior (Butts & Rich, 2008). Examples of virtues are compassion, courage, and honesty. There is certainly value to espousing particular virtues and trying to live up to one's ideals. In reality, this can lead to frustration and stress, because people fall short of their perceptions of perfection. There can also be challenges when people have differing virtues that they believe to be most important.
Causistry focuses on case precedents. What happened in previous cases is used as a guide for deciding what should be done in a current case. The value to this approach is that it addresses the reality of a particular "case" or situation and looks for consistency in judgment from case to case. Cases related to decision-making for minor children and to withdrawal of life support are often cited as "precedents" for handling new cases. The disadvantage is that not all cases are alike, and differences may outweigh similarities. This approach historically does not take those nuances into account, though more recent use of this theoretical framework has taken a more evidence-based approach-using past case precedents as guidelines but putting information into context with a current clinical dilemma (Butts & Rich, 2008).
Utilitarianism, or consequentialism, focuses on the "usefulness" or the value of the consequences of a decision, rather than on what "should" be done or what has been done in previous cases. Typically, the focus is on the perceived value to the greatest number of people. For example, the consequence of requiring people to wear seat belts in cars is focused on the greatest good (fewer injuries) for the greatest number of people, even though there is resistance by some people to having the law dictate their behaviors.
Deontological perspectives are based on rules and duties. The focus is on rational thought, and making choices based on what one "should" do rather than on what will produce the best outcomes or what one believes to be "ideal." Reason, rather than emotion, is the driving force behind deontology (Butts & Rich, 2008). The process of obtaining informed consent, for example, implies rational thought on the part of the provider and the patient-information is shared, questions are answered, and the patient chooses to participate in or decline the procedure. The provider has the duty to provide the information; the patient has the duty to be sure there is clarity and understanding prior to making a choice.
Principalism is based on basic principles that guide actions and decision-making. There are four key principles that have become familiar to most people as foundational to ethical issues in the clinical setting. These include autonomy, nonmaleficence, beneficence, and justice. Each principle will be described in the following paragraphs.
The principle of autonomy is based on the patient's right to be self-directed. Patient rights documents, informed consent processes, and protection of privacy and confidentiality are all examples of ways autonomy is operationalized in the healthcare environment. Interestingly, nurses often use the term "noncompliant" to characterize a patient who does not follow the plan of care the nurse believes to be "right." If, in fact, the nurse supports the principle of autonomy, there would be no such thing as "noncompliant." It would simply be that the patient is choosing to be self-directed, based on what he/she believes to be "right" in that particular situation.
The principle of nonmaleficence essentially means "do no harm." The focus of the healthcare team should be on helping the patient get better, have a positive birth or peaceful death experience, relieve pain, or in other ways, "do good." Harm should be avoided, or at least minimized. For example, a medication may be chosen for a patient because it is the most likely drug to produce therapeutic benefits, even though the side effects may be uncomfortable. One consideration in the area of nonmaleficence is something referred to as the principle of double effect. This principle holds that there are some cases in which it is impossible to avoid harm. Take, for example, the situation of a 26-year-old woman with a diagnosed tubal pregnancy. Allowing the pregnancy to continue will inevitably cause harm to both mother and embryo. Surgical intervention causes pain to the mother, removal of the embryo, and potentially damage that may affect future fertility of the mother. While there are no "good" options, and harm will occur regardless of the option taken, the standard of care is surgical intervention to protect the life of the mother.
The principle of beneficence, sometimes considered the opposite of nonmaleficence, is doing good. The Code of Ethics for Nurses with Interpretive Statements (ANA, 2001), emphasizes the responsibility of the nurse to practice with compassion and respect for the dignity, worth, and uniqueness of every individual-regardless of color, sex, age, cultural heritage, or any other factors. Further, the code states that the primary commitment of the nurse is to the patient. Being committed to "doing good" for the patient, however, is not to be confused with "doing whatever the patient wants." The recent focus on patient satisfaction surveys has presented some interesting challenges in relation to beneficence. While it is generally perceived that the patient will rank higher on the "happiness index" if he gets what he wants, this may not be in the best interest of the patient. Consider the post-operative patient who wishes to remain in bed for the first three days after his surgical procedure. It may be tempting to acquiesce to this request, with the assumption that the patient will be more satisfied if he is allowed to do what he wants. However, the standard of care is early ambulation for the purposes of promoting healing and preventing complications from immobility. Rather than accommodating the patient's request, the better option would be to explain to him why it is important to ambulate, provide medication as appropriate to provide comfort during those first few ambulation attempts, and provide assistance as needed with the ambulation. The patient may be given the choice, for example, as to whether he prefers to ambulate before or after lunch. Patient satisfaction can be facilitated by clear explanations of rationale based on evidence and standards of care, supportive assistance, and acknowledgement of the need of the patient to retain some sense of control. Another word of caution relates to paternalism, or doing what WE think is in the best interest of "doing good" for a patient. A provider may determine, for example, that it would not be in the patient's best interest to tell him that his wife was injured in the same automobile accident that caused his hospitalization. The thinking of the provider is that withholding this information is "doing good," because it would cause increased anxiety for the patient if he knew his wife was also in the hospital. However, refusing to provide the patient with answers to his questions may have exactly the opposite effect, and may cause even more anxiety than simply and truthfully answering the questions.
The principle of justice relates to providing people with the same options and choices about their care, without consideration of cost, culture, or other potentially discriminating barriers. The caveat to this, however, is that the focus is not on treating everyone "equally." This would suggest that everyone is treated exactly the same way, which is impossible because every clinical case is unique and requires individualized care. Distribution of healthcare resources is an issue when demand exceeds supply. Consider organ transplantation-there are significantly more people waiting for organs than there are compatible organs available for transplantation. Some sort of system is therefore necessary to ensure that resources are maximized-the organs are used appropriately and patients get appropriate care for their conditions. Another example of the use of the principle of justice is triage. First used in military situations, triage is now common in emergency departments, urgent care centers, and other areas where care needs must be prioritized. While each person has the right to be seen by a healthcare provider, those whose conditions are least stable are the highest priority for treatment.
These principles are widely used in today's healthcare system. While there is significant benefit to considering individual cases in the context of preserving autonomy, doing good, avoiding harm, and promoting equity, a major area of concern is that these principles are often in competition with each other. In the case cited earlier with that patient who is self-directed, he is exercising autonomy but runs the risk of doing harm by not following the plan of care. The provider who feels it appropriate to address a patient's complaints of pain by always prescribing narcotic analgesics may fuel a drug abuse problem-thus doing good is outweighed by the possibility of causing harm. The four principles presented here are effective tools in considering ways to address ethical challenges, but their benefits and potential downfalls must be taken into consideration specific to each case.
Caring or feminist ethics is the newest theoretical perspective. The caring approach relates to more traditional female-based problem solving processes focused on different stakeholder's perceptions, values, and needs. The role of emotions is emphasized more than reasoning, duty, or the foundational beliefs of the other theories. Today's complex healthcare world typically requires application of a blend of theories rather than a purist approach to only one theoretical framework.
Examples of Contemporary Ethical Challenges
The complexity of today's healthcare environment and the availability of new technology and treatment options have created significant areas of challenge in addressing options and choices. In the "old days" of health care, it was relatively easy to determine that a patient was "dead"-breathing and heart beat ceased, and life stopped. Today, there are pacemakers, internally implanted defibrillators, ventilators, and substantial other types of technology that have made the determination of "dead" much more challenging. These dilemmas don't just come at time of death-they are exemplified by examples throughout the life span. Following are some examples.
Beginning of Life
There are numerous clinical ethical issues surrounding the beginning of life. The advent of in-vitro fertilization in the 1970's heralded a significant era in childbearing options. Subsequent study of genetics and the human genome project have allowed science to now play more and more of a role in prenatal decision-making. Think about the sequence of challenging choices surrounding in-vitro fertilization: how many ripe eggs should be harvested for fertilization? If six eggs are fertilized, how many should be implanted? If only two are implanted, what should happen to the other four? There are "banks" that store fertilized eggs, but what happens if the "parents" divorce or one parent dies? Who "owns" the tissue? Prior to implantation, it is possible to perform genetic testing-embryonic structures with genetic conditions that may present significant challenges to the life of a child can be identified, and parents may choose not to undergo implantation. However, it's not a huge stretch to think that, if genetic traits for diseases can be identified, parents might also request identification of a potential child's likelihood of being intelligent, being tall, or having blue eyes. At what point should there be limits on the types of choices that are "allowed"? Who should make those decisions- Parents? Physicians? Payers?
Stem cell research has been another recent area of controversy. Because one source of stem cells is "left over" embryonic structures from in-vitro fertilization, there has been considerable discussion about the relative merits of using these cells for research purposes. From the perspective of "doing good," or beneficence, proponents of embryonic stem cell research argue that such research can lead to development of cells that can be used to treat a vast array of disease conditions. On the other hand, opponents, from the perspective of nonmaleficence, or not doing harm, argue that this budding life structure should not be destroyed. Emergence of new technologies, such as induced development of stem cells that are not taken from embryonic tissue (Perry, 2011), may offer an alternative that provides more "good" and less "bad" options.
Genetic testing itself has created ethical dilemmas. Based on a test that shows a probability that a person is at high risk for development of a medical condition, what actions should be taken? Some will suggest that extra vigilance and regular screening is appropriate, others will advocate for surgical intervention-prophylactic mastectomy is an example. Then there are issues to consider in relation to others in the family. If a 36-year-old mother tests positive for a gene for breast cancer, what does she tell her 17-year-old daughter? What intervention, if any, is appropriate for the daughter? Hamilton, Bowers, and Williams (2005) conducted a study to ascertain perceptions of people who had received genetic test results and those who had chosen not to receive these results in relation to what they shared with their family members. Factors identified by study participants included assessment of effects on family members, the content of information shared, and timing of disclosures. This is a complex process, often requiring guidance from members of the healthcare team, including genetic counselors, nurses, physicians, and others.
There are standards of care for all medical interventions that have been set by professional organizations, based on best available evidence. However, individual cases still must be considered in relation to those standards. Patients, providers, and other interested parties must evaluate issues on a case-by-case basis. The decision-making matrix discussed later in this study can be a tool to assist in the decision-making process.
Children are generally not considered capable of giving informed consent for medical procedures or determining best options for care. However, who has the authority to make these decisions on behalf of a pediatric patient? Typically, the parents are considered the decision-makers. However, custody issues sometimes cloud the process. Even where there is unity between the parents, they may make a choice that the healthcare team does not feel is in the best interest of the pediatric patient. Then what happens? At times, providers have chosen to go to court to get authority to implement the treatment they determine to be best, over-riding the rights of the parents. In other cases, particularly with older children, parents have been able to discuss options and choices with healthcare providers and may choose options such as herbal or alternative treatment in lieu of "mainstream" medical intervention. At what age are children able to make choices for themselves, or at least to participate in discussions about care options? How much "weight" should the child's opinion carry? What if the child and the parents do not agree?
What if the "parent" is a "child"? There are times when a 17-year-old is the mother of a 9-month old who needs medical care. Who has the ability to authorize care for the child? For the mother? States have different laws, so it is important to know the laws in the state where you practice to be sure you and your organization are following appropriate legal guidelines. Again, though, within the context of the law, individual cases must be considered as unique situations, and stakeholders must be engaged with providers in the decision-making process.
What happens when healthcare team members are concerned about the choices an older adult makes to stay in his/her own home, when the team perceives that this is not the "best" environment for the patient? Healthcare providers may believe that the environment is not as clean as they would like, that there are potential safety risks, or that the patient may not have the ability to prepare nutritious meals. However, the question becomes one of capacity-does the older adult have the capacity to make those decisions? If so, his/her right to autonomy is typically honored-even if the conditions are not optimal. This is a good example of the type of conflict that often arises in a principle-based theoretical framework-there is conflict inherent in the framework, with the patient's right to autonomy being at apparent odds with the staff's desire for beneficence-doing good. Typically, in situations such as this, autonomy prevails, as long as there is not imminent threat of harm to the patient.
End of Life
There are significant ethical issues surrounding end-of-life choices and decision making, regardless of the age of the patient. Some patients have advance directives, which support their autonomy in the decision-making process. Often, however, there are no advance directives in place. Family members, finding themselves in the difficult situation of grieving the pending loss of a loved one, are often challenged to make choices. It is helpful to remind people in this situation that the best approach is to ask "What would your mother want, if she were able to speak and make her wishes known?," rather than "What do you want to do in this situation?" Focusing on the values and goals of the patient, rather than on various family members, is often a helpful way to diffuse family conflict.
Sometimes, language used by members of the healthcare team can add to the distress of family members. For example, what does "terminal" mean? What does "futile" mean? Are we clear in our explanations about what is involved in CPR or what "intubation" really is? Helping patients and families understand the terminology and the implications of their decisions about use of technology and other resources can provide support for them in working through the decision-making process.
As noted earlier, new technology and treatment options have compounded the potential for ethical dilemmas. Take, for example, the ability to implant cardioverter-defibrillators (ICDs) which have provided valuable assistance to patients at risk for life-threatening dysrhythmias. What happens when these patients become terminally ill? Do the patient and/or family want electrical shocks to continue while the patient is actively dying? Who makes the decision to deactivate the ICD? When? A literature review by Russo (2011) suggests that neither patients nor providers are well-equipped to address these dilemmas today. Opportunities exist for patient and staff education, dialogue about end-of-life decisions, and consideration of various therapeutic and comfort-related care options.
Moral distress is a phenomenon experienced by nurses and other healthcare providers when they feel that there is a disconnect between what they feel ought to be done and what they are able to do. Moral distress is defined as "psychological disequilibrium" that occurs when, for whatever reason, the nurse is not able to provide the care that is perceived to be "right" or "best" for the patient (Corley, 2002). This may include situations of omission (care perceived to be appropriate is not able to be provided) or situations of commission (the nurse provides the care, even though he/she does not perceive it to be "right" for the patient).
The American Association of Critical Care Nurses has published a position statement (AACN, 2008) on the topic of moral distress, calling it a serious problem in nursing that results in significant physical and emotional stress. This organization advocates that every nurse and every employer are responsible for working toward strategies to mitigate the potentially harmful effects of moral distress on both patients and nurses. The position statement outlines steps that can be taken by the individual nurse and by the employer in order to empower nurses to be actively engaged in addressing the issue. Note that the position statement clearly does not say that moral distress should be eliminated; rather the imperative is to recognize and proactively deal with this issue.
Writing in the January, 2010, issue of the Online Journal in Nursing, Dr. Marla Weston discusses the concept of control over nursing practice. She advocates that autonomy in nursing includes "the ability to act according to one's own knowledge and judgment," within the framework of relevant laws, rules, and organizational policies and procedures. Given that moral distress is a factor in the context in which nurses practice, part of the value of control over one's practice is the ability to participate actively in strategies that will empower nurses to affect change. This may occur in the form of new policies and procedures, new process improvement initiatives, or new strategies through which nurses and physicians collaborate. Weston cites numerous sources supporting the fact that autonomy and control over nursing practice have a direct impact on the quality of nursing care provided to patients.
Assisting Patients, Families and Colleagues in Addressing Ethical Dilemmas
Every nurse is accountable for having knowledge and applying skills related to addressing ethical dilemmas in the healthcare environment (Trossman, 2011). While every nurse is not and is not expected to be an ethicist, nurses are expected to be familiar with the Code of Ethics for Nurses, ethical theories and perspectives related to clinical dilemmas, and aware of his/her own moral perspectives relative to health issues. Further, the nurse is accountable for assessing his/her own ability with regard to intervening in situations where there are ethical dilemmas and knowing how and when to access appropriate assistance.
A recent study conducted by Pavlish, et. al. (2011) demonstrates that nurses were often aware of the presence of actual or potential ethical dilemmas, but "chose not to pursue their concerns beyond providing standard care" (p. 385). This led, at times, to nurses' feelings of moral distress and regret that they had not done enough to meet the holistic needs of their patients. These authors speak to the fact that failure of nurses to recognize and intervene in ethics-laden clinical situations can result in team conflicts that "erupt and erode quality care" (p. 394). They advocate that helping nurses develop moral reasoning skills and use of evidence-based interventions in ethical dilemmas will strengthen quality patient care.
The Ohio Nurses Association (2006) developed a process to guide the registered nurse in the process of working through ethical dilemmas. The steps include:
* Identifying the existence of the ethical dilemma (conflict in values, not a procedural issue)
* Gathering and analyzing relevant information-including identification of stakeholders, interdisciplinary team members, and other sources of relevant information
* Clarifying personal values and moral position, including the moral perspectives of other "players" in the scenario
* Determining options, based on careful consideration of alternatives and their benefits/ risks
* Making responsible decisions about a course of action or recommendations, in collaboration with other interested parties
* Evaluating the impact of the action and outcomes
These steps can assist the nurse in assessing ethical dilemmas, deciding on a plan of action, and implementing the plan. While the focus here is on the nurse, it is important to remember that the nurse is one member of an interprofessional healthcare team that needs to work collaboratively with patients and families in addressing these ethical dilemmas. The following case study highlights use of the above process.
You are a nurse in an oncology clinic. Your patient is in end-stage metastatic cancer involving bone and brain. He rates his depression as a 9 on a 1-10 scale and his pain as an 8 during this visit. He states that he is very tired of the pain, frustrated by lack of support from his family, and fearful of dying. While he has not mentioned suicide, you are concerned that he may be considering ending his own life. His family provides transportation to the clinic appointments, but shows little interest in his care. During the last visit, the topic of hospice was introduced but was immediately rejected by the family. The patient was silent on the issue.
Is there an ethical dilemma? Remember that an ethical dilemma relates to a conflict in values. In this case, there may be ethical dilemmas in several areas: possible suicide, reasons for lack of family support, concerns about dying that may be based on religious, cultural, or other personal moral beliefs. However, there really is not enough data yet to determine whether there is really an ethical dilemma, or whether there is lack of sufficient information. For example, sometimes taking time to talk with patients and families about hospice services allays their anxiety and enables them to receive support that helps them through the dying process. Lack of understanding about hospice services is generally a knowledge issue, rather than an ethical dilemma. On the other hand, the patient may believe that suicide is the answer to his pain and distress, but the healthcare team believes that there are better options to managing his depression and pain. Now there is a conflict in values-the patient's right to autonomy as compared to the responsibility of the healthcare team to "do good" and avoid doing harm.
Gathering and analyzing relevant information- what more do you need to know about this situation? Why does the patient believe that suicide is the best option? Who are the involved family members? For what reasons have they not been involved in supporting him up to this point? Or perhaps, is there a disconnect between what he perceives as "support" and what they perceive they are already doing? Who are the involved members of the healthcare team? What are their perspectives regarding appropriate care for the patient? What is the standard of care in similar cases? What are relevant legal issues that might need to be considered?
Clarifying values and moral positions-What personal, religious, cultural, or other values are underlying the patient's current perspective? What values underlie the family members' individual and/ or collective perspectives? What goals does each party have? What are the moral positions of the members of the healthcare team?
Determining options--What choices do the patient and family have? What are the consequences of the various options? Remember that our opportunity for assisting in these difficult decisions is short term, but the family will be living with the consequences long after our interaction with them is over. What choices do healthcare team members have? What if the patient and/or family's choices do not support the standard of care? How can you assure that all parties have the opportunity to have their voices heard?
Making reasonable decisions--What is "reasonable" for both patient/family and healthcare team? How can there be congruence and mutual support around resolution? Based on the decision made, how will best care be provided going forward? How can continuous support for the patient and family be sustained?
Evaluating impact of actions and outcomes--Obviously this occurs after the issues have been fully examined, options explored, and courses of action chosen. There will typically be opportunity for some short term evaluation during the time care is provided. However, longer-term evaluation data will help to establish the true value of the deliberation and decision-making process. Strategies to collect this data must be explored in the context of quality care. These outcomes will help to establish evidence to support the processes that have been utilized in addressing and resolving the ethical dilemma.
The Role of Ethics Committees
When nurses are struggling with ways to assist patients and families, or to help themselves or their colleagues, in dealing with ethical dilemmas, the organization's ethics committee can be a source of assistance. According to the American Society for Bioethics and Humanities (2011, p. 2),
"Healthcare ethics consultation is a set of services provided by an individual or group in response to questions from patients, families, surrogates, healthcare professionals, or other involved parties who seek to resolve uncertainty or conflict regarding value-laden concerns that emerge in health care." Note that the role of the ethics committee is to help in the values-conflict resolution process, not to provide "answers" or tell people what to do. Consultations may occur in a number of fashions-- an individual consultant, a select team of resource personnel, and a committee comprised of ethics committee members and other stakeholders are among the common models.
The American Society for Bioethics and Humanities (ASBH, 2011)) has established competencies for the process of providing ethics consultations in the healthcare environment. These include:
* Moral reasoning and ethical theory
* Common bioethical issues
* Healthcare systems in general
* Clinical context for particular cases
* Facility policies, processes relative to a particular case
* Beliefs and values of the population served by the facility (both patients and staff)
* Relevant codes of ethics/professional conduct and accreditation standards
* Relevant health law
* Assessment and analysis of ethical issues
* Process skills for guiding conversations and problem solving
* Facilitating formal meetings
* Evaluation and quality improvement
* Interpersonal communication
Obviously, not every member of an ethics committee or consultation team will be an expert in each of these knowledge and skill areas. However, assuring that collectively, team members have this type of expertise will support the effectiveness of the work of the ethics committee.
Ethics committees and consultations guide the process of discussion and deliberation, considering various options and their relative benefits and risks. To accomplish this, consultants and committee members need to be aware of their own moral values, ensuring that they are able to separate personal beliefs from deliberations related to beliefs and values of the parties involved in the particular issue under consideration. The committee can provide guidance in helping the interested parties consider various ethically appropriate options and their consequences. Again, the role of the ethics committee is not to stipulate what is "right" or what people "should" do. These deliberations can and should take time for the views and values of all parties to be heard and analyzed--ethics committees are not called to "put out fires" or to police the actions of others. The outcome of an ethics committee deliberation is typically recommendations for the primary care team, which then selects those options that are most appropriately suited to the situation at hand.
Nurses who are interested in more involvement in the process of addressing ethical dilemmas can apply to be members of their organization's ethics committee. These committees are typically multidisciplinary in nature, and nursing representation is a key component of effective committee composition. For the nurse who works in an organization that does not have an ethics committee, several options exist. The nurse could work with others in establishing such a resource. Following ASBH guidelines would help in developing an effectively functioning committee. Another choice might be for the nurse to consider other sources of information--referring to ethical decision-making guidelines published by professional associations, talking with colleagues who have faced similar dilemmas in like work environments, and participating in ethics workshops and conferences.
Ultimately, nurses are accountable for addressing ethical issues as part of quality patient care. There are actions that nurses can take to assess their own moral positions; assess presence of an ethical dilemma for patients, families, and/or healthcare team members; assist in problem-solving of ethical dilemmas; and collaborate as members of the healthcare team to provide quality care in ethically challenging situations. Dealing with ethical dilemmas is not solely a nursing issue, but nurses are key players in application of ethical principles in the healthcare environment.
Both organizational and clinical ethical dilemmas pose challenges in today's healthcare settings. Laws, practice regulations, accreditation criteria, and facility policy affect decision-making around organizational ethical questions and issues. Various theoretical perspectives guide analysis and decision-making for clinical ethical dilemmas. The Code of Ethics for Nurses clearly identifies the accountability of the nurse to apply ethical standards in patient care. There are no clear answers to ethical dilemmas in clinical practice--the role of the nurse, as a member of the interprofessional care team, is to identify potentially ethics-related situations, work with others to address these issues, and provide holistic support for patients, families, and colleagues.
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What Do I Do Now? Ethical Dilemmas in Nursing and Health Care Post Test and Evaluation Form
DIRECTIONS: Please complete the post-test and evaluation form. There is only one answer per question. The evaluation questions must be completed and returned with the post-test to receive a certificate.
Date: __ Final Score: __
Please circle one answer.
1. Organizational ethics relates to:
a. Accreditation requirements
b. Expectations for people's behavior at work
c. How the employer establishes policies
d. Difficult decisions faced by staff, patients, and families in the healthcare organization
2. One's moral view provides:
a. A sense of what is right and wrong for that person
b. An ethical framework for decision making
c. Expectations about the behavior of others
d. Guidelines for helping other people make decisions about troubling issues
3. Clinical ethics relates to:
a. Decision making about complex moral issues in the healthcare environment
b. Determining the right thing to do when patients have different perceptions than staff
c. Expectations of staff in the clinical environment
d. Relationships between facility policies and patients' rights
4. The current Code of Ethics for Nurses was published in:
5. Professional ethics includes expectations for behaviors in the work environment and as a:
a. Facilitator of patient/family decision-making
b. Member of the profession
c. Participant in an ethics consultation
d. Specialist in a particular area of clinical practice
6. The first code of ethics for nursing in the United States is also called the:
a. Code of Ethics with Interpretive Statements
b. Nightingale Pledge
c. Nursing's Social Policy Statement
d. Scope and Standards of Nursing Practice
7. Board of nursing actions related to inappropriate behavior of the nurse can result in:
a. Civil or criminal court charges
b. Disciplinary action on the nurse's license
c. Employer commendations
d. Policy changes within the facility
8. The concept of "intellectual property" means that If you develop a patient education handout at work, that material:
a. Belongs to you
b. Can be marketed or sold to others by either you or the employer
c. Is the property of the employer
d. May be purchased from you by the employer
9. The Code of Ethics for Nurses states that, among other things, the nurse is accountable to:
a. Advocate for advancement of the profession
b. Advocate for the employer
c. Focus primarily on carrying out physician orders
d. Maintain patient satisfaction, regardless of the patient's requests
10. The beginning of modern ethics is often thought to have started with:
a. Florence Nightingale
b. Onset of the 21st century
c. The Nuremburg Trials
d. World War I
11. Ethical dilemmas relate to:
a. Conflicts in values
b. Health care differences of opinion
c. Perceptions of right and wrong
d. Religious or cultural issues
12. Consequentialist ethics is based on:
a. Clarification of patient/family goals in relation to the consequences of proposed medical actions
b. Outcomes of decisions patients make in relation to the risks inherent in medical interventions
c. Rational thinking and critical analysis of a given situation
d. Whether the proposed action will yield the greatest possible benefit to the largest number of people
13. The theoretical perspective that focuses on the four key principles of ethics has been controversial because:
a. Focal points may change, depending on the healthcare setting
b. Nonmaleficence should be the primary standard
c. The four components sometimes represent competing perspectives
d. The patient's right to autonomy is paramount
14. The principle of autonomy suggests that:
a. Patients have the right to make choices in the direction of their care
b. The patient is always right
c. The provider must seek informed consent prior to any procedure
d. What the patient wants should always be the provider's priority
15. Drivers for ethical concerns in today's healthcare settings include:
a. Accreditation requirements
b. Mandates from third-party payers
c. Rapid advances in technology
d. Use of electronic medical records
16. The doctrine of double effect holds that an action may be justified, even if it has a foreseeable harmful effect, if:
a. The harmful effect is not predicted to be fatal if implemented in conjunction with other measures
b. The patient requests that the procedure be done regardless of the anticipated consequences
c. The therapeutic benefit outweighs the harmful effect
d. There is no difference in perceived value between the two options
17. A recommendation for health care ethics committees is that:
a. Members should be aware of the values and potential challenges of various theoretical perspectives
b. One particular theory should be chosen and used in all cases
c. Only research-based data should be used when addressing ethical issues or making decisions
d. Theoretical perspectives are not important for the practical work of ethics committees
18. The principle of justice suggests that:
a. All patients should be treated the same, regardless of their preferences or family's wishes
b. People should have access to the same options and treatments without discrimination, given the clinical uniqueness of a patient's condition
c. Responsibility rests with the provider to ensure that every patient receives the same level of care, regardless of the medical diagnosis or unique individual variables
d. There are no constraints to any individual who wishes to receive care for any health condition
19. An institutional review board would be used when a person is interested in:
a. Analyzing use of evidence-based practice
b. Becoming involved in quality improvement activities
c. Conducting research on human subjects
d. Developing a continuing education activity
20. An important skill in ethics assessment and analysis is:
a. Identifying a range of ethically acceptable options and their consequences
b. Making sure the consultant or committee's recommendation is followed
c. Rapid intervention to avoid delayed care
d. Writing the consultation report clearly and concisely
21. An ethical standard used in relation to continuing education is:
a. Assessing learner preferences for topics
b. Developing objectives for the learning activity
c. Evaluating the quality of the learning experience
d. Providing learning activities without bias
22. The term "noncompliant" is incompatible with a belief in:
23. An example of application of the principle of justice is:
b. Do not resuscitate orders
c. Evidence based practice
24. In the arena of clinical ethics, the best approach is:
a. Avoidance of controversial issues
b. Defaulting to physician recommendations
c. Quick action
d. Thoughtful deliberation
25. Moral distress relates to a disconnect between:
a. Facility policies and employee behaviors
b. Family choices and their religious or cultural values
c. What the healthcare provider wants to do and what he/she is able to do
d. Whether or not family members are allowed to make choices for their loved ones
1. Were you able to achieve the following objectives Yes No
a. Differentiate between   organizational and clinical ethics.
b. Define an ethical dilemma.  
c. Identify steps nurses can   take to assist patients and families in working through ethical dilemmas.
2. Was this independent study an effective method of learning   If no, please comment:
3. How long did it take you to complete the study, the post-test, and the evaluation form?
4. What other topics would you like to see addressed in an independent study?
Table 1. Provisions of the ANA Code of Ethics for Nurses 1 Practice with compassion and respect for dignity, worth, and uniqueness of every individual 2 Primary commitment is to patient: individual, family, group, or community 3 Promote, advocate for, and strive to protect health, safety, and rights of the patient 4 Responsible and accountable for individual nursing practice; determine appropriate delegation of tasks consistent with obligation to provide optimum care 5 Owes same duty to self as others; responsible to preserve integrity & safety, maintain competence, & continue personal / professional growth 6 Participate in establishing, maintaining, and improving healthcare environments / conditions of employment 7 Participate in advancement of profession through contributions to practice, education, administration, & knowledge development 8 Collaborate with other healthcare professionals & public in promoting community, national, and international efforts to meet health needs 9 Profession of nursing is responsible for articulating values, maintaining integrity, & shaping social policy Source: ANA Code of Ethics for Nurses with Interpretive Statements, 2001