Download Chapter 11: Ethical Decision Making

Chapter 13
Ethical Decision Making
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
Introduction
Changes in interprofessional roles, advances
in medical technology, availability of
information online, revisions in patient care
delivery systems, and heightened economic
constraints, have increased the complexity of
ethical issues in the health care setting.
2



Nurses in all areas of health care routinely encounter
disturbing moral issues, yet the success with which
these dilemmas are resolved varies significantly. As
the complexity of issues intensifies, the role of the
advanced practice nurse (APN) becomes particularly
important in the identification, deliberation, and
resolution of difficult moral problems.
Although all nurses are moral agents, APNs are
expected to be leaders in resolving moral problems,
working to create ethical practice environments, and
promoting social justice in the larger health care
system.
“We need to develop our hearts as well as our minds”
Hope 2004
3
APN Role in Moral and
Ethical Issues

Ethical decision making is a core competency
of APNs; they are leaders in:



Recognizing and resolving moral issues
Creating ethical practice environments
Promoting social justice in the larger health care
system
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
4
QUALITIES OF ETHICAL NURSES

Moral integrity: truthfulness, honesty,
courage.

Concern: advocacy & power.

Culturally sensitive care.

Respect for others.

Confidentiality.
5
Types of Moral Problems



Moral dilemma: Occurs when obligations require
or appear to require that a person adopt two (or
more) alternative actions, but the person cannot
carry out all the required alternatives
Moral uncertainty: The right action is not clear
Moral distress: The right action is clear, but the
actor feels constrained from carrying out action
(because of institutional obstacles)
(Adapted from Jameton, 1984, 1993)
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
6
Moral Distress: A Newer
Definition

“Moral distress is the experience of being
seriously compromised as a moral agent in
practicing in accordance with accepted
professional values and standards. It is a
relational experience shaped by multiple
contexts, including the socio-political and
cultural context of the workplace
environment.”
(Varcoe et al., 2012, p. 60)
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
7
Ethical Dilemma Themes



Communication
Interdisciplinary Conflict
Management of Multiple Commitments
and Obligations
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
8
Communication Goals





Problem: Erosion of open and honest
communication
Some ethical disputes reflect inadequate
communication rather than a difference in
values.
All team members are accountable for
providing succinct and precise information
Listening is as crucial as verbal skills
Focus on common goal of patient care
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
9
COMMUNICATION

Clear and definitive communication with patients
and families will increase understanding, lead to
more knowledgeable decision making, and may
improve compliance with current therapies.

Listening involves recognizing and appreciating
various perspectives.

Allow others the necessary time to form and
present their thoughts and ideas.
10
Interdisciplinary Conflict


Differing positions can lead to creative and
collaborative decision making or to a
breakdown in communication
Interdisciplinary theme prevalent in
presentation and resolution of ethical
problems
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
11
INTERDISCIPLINARY INVOLVEMENT

Issues
 Refusal
of treatment.
 End-of-life decision making.
 Cost containment.
 Confidentiality.

Moral dilemmas that often surround end-of-life
decision making provide an excellent example
of interdisciplinary issues that call for a
collaborative approach.
12
Multiple Commitments


Fidelity: Obligation to be faithful to
commitments and promises
APN fidelity to self in addition to:




The patient and family
Physicians and other colleagues
The institution or employer
The larger profession
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
13
Have you
experienced any
ethical dilemma
during your
career?
14
Examples of Ethical Issues:
Primary Care




Insurance reimbursement
Patient refusal of appropriate care
Lack of power to effect change
Being asked to see an excessive number
of patients
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
15
Examples of Ethical Issues:
Acute and Chronic Care
•
•
•
•
•
•
Pain management
End-of-life care
Advance directives
(Shannon, Foglia, & Hardy, 2009)
Assisted suicide
Confidentiality
Transmitting health information
electronically
(Rajput & Bekes, 2002)
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
16
Examples of Ethical Issues:
Societal Issues



Cost containment vs. quality of care
Scientific and technological advances
Ethical problems related to research:



Informed consent
Protecting vulnerable patients from undue risk
Protecting subject privacy
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
17
Examples of Ethical Issues:
Access and Justice Issues


Issues of social justice and equitable access
Allocation of scarce health care resources



“Brain drain”: leaving nurses from
underdeveloped to developed countries.
E.g. organ transplantations
Tension in caring for the individual patient
vs. the larger population
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
18
Legal Issues




Legal precedent has emerged, reflecting
changes in society’s moral consensus
Often, no relevant law → ethical decision
making
Judicial aim is to interpret law, not satisfy
ethical concerns of all parties
Law may contribute to creation of new
dilemmas
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
19
Phases of Ethical Decision Making
Competency Development
Phases are sequential
 Phases 1 and 2 should be taught in
graduate education
 Phases 3 and 4 evolve as APNs mature
in roles
 Phase 4 relies on competencies
of DNP-prepared APNs

Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
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Ethical Decision Making
Competency




Phase 1: Knowledge development
Phase 2: Knowledge application
Phase 3: Creating an ethical environment
Phase 4: Promoting social justice within
the health care system
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
21
Phases of Development of Core
Competency
for Ethical Decision Making

See Table 13-1
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
22
Phases of development of core competency for ethical
decision-making
Phase
Phase 1:
knowledge
developmentmoral sensitivity.

Knowledge
Ethical theories
Ethical issues in
specialty
Professional code
Professional
standards
Legal precedent
Skill/behavior
Sensitivity to ethical
dimensions of clinical
practice( values
clarifications-sensitivity to
fidelity conflict).
Gather relevant literature
related to problems identified.
Evaluate practice setting for
congruence with literature.
Identify ethical issues in the
practice setting and bring the
attention to the other team
members.

23
Phases of development of core competency for ethical
decision-making
Phase
Knowledge

Phase 2:
knowledge
application

Phase 3:
Creating an ethical
environment.


Skill/behavior
Ethical decisionApply ethical decision-making
making models
models to clinical problems.
Mediation/facilitation
Use of skilled communication
strategies
regarding ethical issues.
Facilitate decision-making by
using select strategies.
Preventive ethics
Awareness of
environmental barriers
to ethical practice.
Role-model collaborative problem
solving.
Mentor others to develop ethical
practice.
Address barriers to ethical
practice through system changes.

24
Phases of development of core competency for ethical
decision-making
Phase
Knowledge
Phase 4:
 concepts of
Promoting social justice.
justice within the Health polices
health care system affecting a
specialty
population.

Skill/behavior
ability to analyze the policy
process.
Advocacy, communication
and leadership skills.
Involvement in healthy
policy initiative supporting
social justice.

25
Phase 1: Knowledge Development




Gains knowledge of ethical standards and
compares these to current practice
Develops moral sensitivity through
clarification of personal and professional
values
Distinguishes ethical problems from moral
distress and other complex clinical problems
Allows APNs to develop language
necessary to articulate ethical concerns
in interprofessional environment
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
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Developing an Educational
Foundation

Education in ethical theories, principles, rules,
and moral concepts provides foundation for
developing skills in ethical reasoning






Building trust in APN–patient relationship
Professionalism and patient advocacy
Resource allocation decisions
Individual vs. population responsibilities
Managing tension between business and
professional ethics
Continuing education programs effective and
necessary
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
27
Content of Ethical Knowledge:
Theories and Approaches


Principle-based approach
Alternative Ethical Approaches





Casuistry
Narrative ethics
Virtue-based ethics
Feminist Ethics
Care-based ethics
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
28
Ethical Theories/Systems

Deontology (formalistic,
principle, duty-based
system)
 Based
on the discovery
and confirmation of a set
of morals or rules that
govern the ethical
dilemma to be resolved
 Principles are absolute
and unchanging
29
Ethical Theories/Systems

Deontology (continued)
 Principles
are based on those fundamental
values that undergird all major religions—
are universal
 Most basic principle is “survival of the
species” through social cooperation
 Focused on the principles of right and
wrong
 Principles echo those in the Bill of Rights
Dr Waddah D'emeh [email protected]
30
Content of Ethical Knowledge:
Principles








Respect for persons
Autonomy
Beneficence
Nonmaleficence
Justice
Veracity
Confidentiality
Role Fidelity
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
31
Autonomy





Self-determination
Elements:
 The ability to decide.
 The power to act on your decisions
 A respect for the individual autonomy of others.
Applications to this principle:
1- informed consent
2- patient self-determination act (1990)
Other applications?
 Maintaining privacy, confidentiality, refusal of
treatment and other patient’s rights.
When restrictions can be applied to individual’s
autonomy??
32
Veracity
The duty to tell the truth and not to deceive others
(how does it relate to autonomy?)
When faced with situations in which lying seems a
rational solution, other alternatives must be sought.
The harm to patient autonomy and the potential
loss of practitioner credibility makes lying to
patients a practice that in almost all cases should
be avoided.

33
THERAPEUTIC PRIVILEGE
Therapeutic Privilege :
The practice of withholding information from
patient in the belief that disclosure is medically
contraindicated.
Nurses might use therapeutic privilege when:-
They are trying to protect the patient from sad &
heart breaking news.
They do not know the fact.

34
Beneficence and Nonmaleficence
Health care professionals try to do good
(beneficence), but if for some reason they cannot do
good, they at least do no harm.
 Beneficence: The duty to do good and prevent or
remove harm.
 Nonmaleficence: do no harm (medical futility),
(slippery slope argument) & (double effect).
 Concepts related to Nonmaleficence: negligence
and extraordinary or ordinary treatments.
 Principles of Nonmaleficence:
• Do not kill.
• Do not cause needless pain.
• Do not incapacitate others

⇒ The important point to notice is that each of these
principles can be met by doing nothing.
35
36
Confidentiality
A patient’s basic right to expect the information he
gives a health care practitioner to be held
undisclosed.
 An important aspect of the trust that patient’s place
in health care professionals.
When can health care professional override
confidentiality?? (Harm Principle)
Child abuse
Contagious disease
STD’s
Wounds caused by guns and knives
Cases in which identifiable third parties would be
placed at risk by failure to disclose information.

37
Role fidelity
The duty to honor commitments
Self-regulation is one of the key elements of
profession. Professional code of ethics are
important documents in the process of selfregulation.
Under no circumstances may the practitioner
place his financial interests above the welfare of
his patients.
Gate keeping within role duty and fidelity
requires the individual practitioners be
responsible not only for their standard of practice
but works to protect the community, patients and
our specialties from abuse of other practitioners.

38
Formal Justice
Justice: refers to fairness, treating people equally
and without prejudice, and equitable distribution
of benefits and burdens.
Social justice: “veil of ignorance” Rawls(1971).
This concept means that if people had a veil to
shield them from their own or others’ economics,
social, and class standing, each person would be
likely to make justice-based decisions from a
position that is free from biases.
39
Ethical Theories/Systems

Utilitarianism (teleological,
consequentialism, situation
ethics)
 An ethical system of utility
 Good: happiness,
pleasure, or lack of
discomfort and pain
40
Ethical Theories/Systems

Main principles of utilitarianism
 Greatest good for the greatest number
 The end justifies the means
 No set rules or principles to govern day-to-
day decisions
 All decisions depend on the situation
 Moral decisions exist to serve a purpose: the
greatest good for the greatest number of
people
 Group “happiness” or good supercedes the
good of the individual
Dr Waddah D'emeh [email protected]
41
Casuistry
•
•
•
•
•
Casuistry is based in Judeo – Christian history.
When people use casuistry, they make decisions
inductively based on individual cases.
When people use casuistry, their ethical decision
making begins as a bottom-up approach by
considering the details of specific cases rather than
beginning from the top down by applying absolute
rules and principles.
In Catholic history, the practice of persons
individually confessing their sins to priests to receive
absolution reflects the use of casuistry.
Today, casuistry is often the method used by
health care ethics committees to analyze the
ethical issues surrounding specific patient cases.
42
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
43
Example
•
•
While a principle-based approach might claim
that lying is always morally wrong, the casuist
would argue that, depending upon the details of
the case, lying might or might not be illegal or
unethical. The casuist might conclude that a
person is wrong to lie in legal testimony under
oath, but might argue that lying actually is the
best moral choice if the lie saves a life
Abortions?
44
Narrative Ethics
•
•
•
•
•
Most people from childhood obtain moral
education about character development from
stories, such as fairy tales.
Similarities to virtue ethics and casuistry?
How can culture affect the narrative ethics?
“narrative approach to bioethics focuses on
the patients themselves: these are the moral
agents who enact choices” (Charon &
Montello, 2002 p. xi).
No one story should be accepted without
critical reflection.
45
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46
Virtue Ethics
It emphasized that the excellence of one’s
character and considerations of what sort of
person one wants to be.
Since the time of ancient Greek virtues have
referred to excellences in regard to persons or
objects being the best that they can be in
accordance with their purpose. Even an
inanimate.
47
Virtue ethics
•
•
•
•
•
Virtues for humans :are habitual, excellent traits that
are intentionally developed throughout one's life.
Aristotle's approach to virtue ethics is grounded in
two categories of excellence:
Intellectual virtues (comes into existence and
increases as a result of teaching) and character or
moral virtues (results from habituation).
These virtues cannot be distinctly separated.
Most virtues consistent with the extremes of excess
and deficiency.
There is a “Golden Mean”
Courage as a virtue, the extremes of rashness and
cowardice.
48
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
49
Feminist Ethics
•
•
•
•
•
•
•
One critical theory that is widely used by nurses.
Under this broad feminist approach is the ethic of care that
originated from the Kohlberg-Gilligan.
Focused on evaluating ethically related situations in terms of
how these situations affect women.
An ethic of care is grounded in the moral experiences of women
and feminist ethics.
Ethic of care emphasizes the importance of traditionally
feminine traits such as love, compassion, sympathy, and
concern about the well – being of other people.
The role of emotions in moral reasoning and behavior is
accepted as being a necessary and natural compliment to
rational thinking.
This position distinguishes an ethic of care from an ethic of
justice and duty- based ethics that emphasize the
preeminence of reason and minimize the importance of emotion
in guiding moral reasoning and the moral nature of one's
relationships.
50
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51
Care-based ethics
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Professional Codes
and Guidelines




ANA Code of Ethics for Nurses (2001)
Guidelines from professional organizations
ICN Code of Ethics for Nurses (2012)
Jordanian code of Ethics, JNMC (2011)
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
53
Content of Ethical Knowledge:
Values




Values: Enduring beliefs that guide choices and
decisions in conflict resolution (Ludwick & Silva,
2000)
Reasoning: involves thinking for oneself to
determine if one’s conclusion are based on good,
logical, foundations. Giving things a reason to exist
Moral reasoning: pertains to reasoning focused on
moral or ethical issues.
Values awareness includes understanding of
complex interplay between cultural values and
ethical decision making
(Buryska, 2001; Ludwig & Silva, 2000)
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
54
Professional Boundaries

Power differential in patient–provider
relationship



Intimacy because of physical contact
Access to personal and private information
Boundary violations


The limits and expectations of the relationship are
breached
Must be immediately confronted, and culpable
individual must be removed from interaction with
patient
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
55
Phase 2: Knowledge Application




Applying knowledge developed in Phase 1 to the
clinical practice area
Translation of ethical knowledge to moral action
An APN accepts responsibility to be a full participant
in the resolution of moral dilemmas
Resources for development
 Ethics committees (functions are: policy
formation, case review, and education)
 Institutional review boards
 Mentoring
 Active seeking of opportunities for ethical
dialogue
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
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Knowledge Application:
Ethical Decision Making



Key step is information gathering, including
contextual information and clarifying problem
Problem identification
Essential component of resolution of ethical
dilemma is moral action
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
57
Sample Ethical Decision Making
Framework

See Box 13-4
1. Gather information
2. Determine that the problem is an ethical
one and identify the type
3. Use ethical theories or approaches to
analyze the problem
4. Explore the practical alternatives
5. Complete the action
6. Evaluate the process and outcome
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
58
Knowledge Application:
Strategies for Ethical Resolution



APN as facilitator
 Objective to achieve integrity-preserving
solution
Strategies:
 Collaboration
 Compromise
 Accommodation
 Coercion
 Avoidance
When “avoidance” is the norm in dealing with
ethical conflict → routinization → nurses became
accustomed and desensitized to ethical conflicts
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
59
Phase 3: Creating an Ethical
Environment
The experienced APN:
 Goes beyond addressing individual situations of
ethical conflict
 Empowers others through role modeling,
mentoring, and informal education, such as ethics
rounds and case discussion
 Coaches and teaches patients/families in ethical
decision making
 Creates ethical environment
 Uses preventive ethics
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
60
Phase 3: Preventive Ethics




Extension of ethical decision making
process; problems are proactively
addressed
Requires early identification of potential
values conflicts and exposure of power
imbalances
Emphasis placed on enhanced autonomy
and inclusion of all parties in resolution
Cultivates ethically responsive
environment of ongoing ethical inquiry
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
61
Phase 4: Promoting Social Justice
Within the Health Care System


The knowledge and skills developed in Phases 1,
2, and 3 are applied to the wider social sphere
The AACN’s DNP essentials emphasize social
justice and need for systems leadership
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
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Phase 4: Social Justice

The APN who reaches Phase 4:




Has an awareness of specific policy issues
affecting the specialty population
Develops skills through involvement in
institutional or community policy groups
Acts as a consultant to policy makers
May serve on an expert panel crafting policy
for specialty groups
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
63
Phase 4: Social Justice (Cont.)

Knowledge required:




Distributive justice: the equitable allocation of
scarce resources
Restorative justice: the duty owed to those who
have been systematically disadvantaged through
no fault of their own
Health policy process
Specific health policies for specialty population
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
64
Evaluation of the Ethical DecisionMaking Competency

Process evaluation





Overview of moral disagreement
Interpersonal skills employed
Interactions between both parties in conflict
Problems encountered during phases of
resolution
Is particularly important in phase 4
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
65
Evaluation of the Ethical DecisionMaking Competency (Cont.)

Outcome evaluation




Acknowledges creative solutions and
celebrates moral action
Includes short and long term solutions, and
satisfaction of all parties.
Prevents recurrence by identifying patterns
Addresses “moral residue” and the Crescendo
Effect
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
66
Barriers to Enacting the Ethical
Decision-Making Competency
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67
Barriers Internal to the APN
•
•
APN’s lack of knowledge and confidence; sense
of powerlessness
Lack of time
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Strategies to Overcome Internal
APN Barriers

Strategies:





Seek out opportunities for ethics education
Values clarification exercises
Gain empowerment through role modeling
Resolve a dilemma in stages
Enlist aid of other colleagues
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
69
Interprofessional Barriers
•
Differing approaches among health care team
members
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Strategies to Overcome
Interprofessional Barriers

Strategies:






Open communication
Cooperation
Develop climate of mutual respect and shared
values
Demonstrated competence
Accountability for role and actions
Developing trust among all team members
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
71
Values/Ethics Competencies
Identified by Interprofessional
Education Collaborative

See Box 13-5
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
72
Patient–Provider Barriers


Barriers arise from issues in patient–
provider relationship
Examples of barriers:



Cultural diversity
Patient lacking an advance
directive
–
Patient non-adherence
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Strategies to Overcome
Patient–Provider Barriers

Strategies:



Change the goals of care in accordance with
patient’s and family’s perspective
In primary care, encourage conversations about
advance directives
Seek additional support from other resource
people
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
74
Organizational/Environmental
Barriers

Barriers:




Lack of support
Time constraints
Lack of continuity of care
Limited resources
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
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Strategies to Overcome
Organizational/Environmental
Barriers

Strategies:




Identify internal and external resources
Know patient as person
Help achieve quality patient outcomes at reduced
cost to system
Track outcomes for data to support system
change
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
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Ethics Resources

See Box 13-6
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
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Conclusion


As a core competency for APNs, ethical
decision making reflects both the art and
science of nursing
APN in key position to:


Assume more decisive role in managing resolution
of moral issues
Create ethically responsive health care
environments
Copyright © 2014, 2009, 2005, 2000, 1996 by Saunders, an imprint of Elsevier Inc.
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