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Ethical and Legal Issues of a Caring-Based Practice

Ethical Issues

  • The World Health Organization (WHO) designated 2020 as the "Year of the Nurse and Midwife."
  • Pope Francis recognized 2020, recalling a nurse who saved his life when he was 20 years old.
  • Gallup Poll results over the past 18 years indicate nursing has been rated first in ethical standards among professions.
  • Healthcare providers face ethical dilemmas daily due to multiple constraints (economic, social, legal).
  • Ethics Overview:
    • Ethics is a branch of philosophy that examines moral choices and considerations of right and wrong.
    • Bioethics: Ethical issues specifically concerning health care.
    • Personal and professional values heavily influence healthcare provider decisions.
    • Clarifying personal values is essential for ethical decision-making.
    • Nursing ethics involve articulating, assessing, exploring possibilities, and appraising moral obligations.
Golden Rules of Ethics (Table 85.1)
  • Christianity: "Do unto others as you would have them do unto you."
  • Judaism (Rabbi Hillel): "What is hateful to yourself, don’t do to your fellow man."
  • Confucianism: "What you don’t want done to yourself, don’t do to others."
  • Buddhism: "Hurt no other with that which pains thyself."
  • Plato: "May I do to others as I would that they should do unto me."
  • Hinduism (Mahabharata): "Do naught to others which if done to thee would cause thee pain."
  • Islam (Muhammad): "Hurt no one so that no one may hurt you."
Modern Challenges in Ethical Practice
  • Increased complexity in healthcare due to:
    • Dehumanizing procedures.
    • Technological developments impacting life quality.
    • Risks of unauthorized confidentiality breaches due to easy access to data.

The Skill of Ethical Action

  • Ethical standards govern healthcare provider actions and decisions, often described as what one "ought" to do.
  • Key philosophical skills for clinicians include:
    • Ability for in-depth questioning.
    • Understanding diverse viewpoints.
    • Engaging in logical arguments and dialectic exchanges.

Professional Codes of Ethics

  • Major organizations have established ethical codes:
    • American Nurses Association (ANA): Code of Ethics for Nurses, adopted first in 1950, frames professional conduct and accountability.
    • American Medical Association: Principles of Medical Ethics.
    • American Hospital Association: Patient's Bill of Rights.
    • International Council of Nurses: Ethical codes guiding international nursing practices.
  • Code serves as a contract between nursing and society, guiding decisions and justifying conflicts between personal and professional values.
  • The 2015 Code highlights the patient as the primary consideration in conflicts of interest.

Ethical Dilemmas

  • Ethical dilemmas usually arise from conflicting principles, obligations, and duties:
    • Conflict between two principles.
    • Conflict between two options viewed as "right."
    • Tensions between immediate actions and deep consideration.
  • Socratic Approach: use reason over emotions for ethical decision-making.
Common Ethical Issues for Healthcare Providers
  • End-of-life decisions (e.g., DNR orders, advance directives, artificial nutrition)
  • Healthcare reform implications.
  • Patient confidentiality breaches.
  • Informed consent challenges.
  • Access to care concerns.
  • Health literacy.
  • Issues related to HIV/AIDS, genetics/genomics, LGBTQ+ persons, and AI.

Theoretical Approaches to Ethical Dilemmas

  • Various ethical theories guide decision-making in healthcare, including:
    • Deontology: Focuses on duties and rules (Immanuel Kant).
    • Teleology: Focuses on goals and outcomes (utilitarianism, virtue ethics).
Deontology
  • Defined as “from being,” emphasizing duties that cannot be breached without moral wrongdoing:
    • Universalizability principle: act according to rules applicable in similar cases.
    • Emphasis on the nature of acts, rights-based duties, and moral obligations.
Teleology
  • Means “study of goals or ends,” focusing on results and happiness:
    • Utilitarian principle: greatest happiness for the greatest number.
    • Community orientation and consideration of future impact.

Application of Ethical Theories

  • Ethical decision-making is shaped differently based on approach:
    • Example:
    • HIV-positive patient: Deontologist: informs partner; Teleologist: considers overall consequences of keeping truth.
    • Terminally ill patient: Deontologist keeps on life support; Teleologist considers patient’s suffering and opts for palliative care.

Ethical Principles in Healthcare

  • Essential principles include:
    • Autonomy: Respect for individual choices and self-determination.
    • Beneficence: Action taken for patient’s benefit and well-being.
    • Nonmaleficence: Do no harm, foundational ethical commitment in healthcare.
    • Veracity: Truthfulness in provider-patient communication.
    • Confidentiality: Protection of sensitive patient information.
    • Fidelity: Keeping promises and maintaining trust.
    • Justice: Fair allocation of resources and treatments.
Autonomy
  • Defines liberty and self-determination in decision-making.
  • Key in informed consent and medical decisions.
  • Parentalism restricts autonomy, undermining a patient’s role in their care decisions.
  • Important Note: Informed consent must be truly informed, allowing for patient autonomy and understanding of risks.
Beneficence and Nonmaleficence
  • Beneficence: Obligation to act for the patient's good.
  • Nonmaleficence: Promises to avoid harm; often challenges altruistic intentions.
Veracity and Confidentiality
  • Veracity: Essential for effective consent and trust-building in the provider-patient relationship.
  • Confidentiality: Complicated by technological advancements, requiring adherence to laws (e.g., HIPAA).
Fidelity and Justice
  • Fidelity: Trustworthiness in following through with commitments to patients.
  • Justice: Complexity of fair distribution of healthcare resources, requiring objective criteria for allocation.

Example Scenarios Demonstrating Ethical Dilemmas

  • Case Study on the case of Shelly, an APRN, facing budget constraints impacting patient care.
  • Patient confidentiality concerning a minor patient's birth control situation.

Resolution Guidelines for Ethical Dilemmas

  • Mnemonic - ETHICAL:
    • E: Examine data.
    • T: Identify decision-makers.
    • H: Humanize options through decision trees.
    • I: Incorporate ethical principles and laws.
    • C: Choose an option based on analysis.
    • A: Act on the chosen decision.
    • L: Look back and evaluate outcomes.

Institutional Ethics Committees (IEC)

  • IECs serve as forums for discussing ethical dilemmas and offering educational resources.
  • Composed of multidisciplinary members including healthcare professionals and community representatives.
  • Vital for providing ethical support, developing policies, and improving institutional guidelines.

Relationship Between Ethics and Law

  • Ethical actions do not always align with legal statutes.
  • Each state regulates nursing through nurse practice acts defining scope of practice.
  • Ethical considerations often guide actions beyond mere legal compliance.

Overview of Nurse Practitioners (NPs)

  • Increasing implementation of the Consensus Model aimed at unifying APRN practice.
  • Regulatory attainment varies by state but supports transparency in APRN roles.
  • Benefits include increased access to care amid healthcare provider shortages.
Legal Issues: Scope of Practice
  • Concerns regarding independent practice and overall operational autonomy of APRNs vary regionally.
Licensure, Certification, and Credentialing
  • Distinctions between the processes of licensure, certification, and credentialing are crucial for professional practice and competency assessment.
Malpractice Considerations
  • Critical importance of understanding legal definitions for establishing malpractice claims.
  • Special attention needed for understanding risks associated with prescriptive authority.
Collaboration and Advocacy
  • Importance of collaboration among care providers, emphasizing shared values and respect.
  • Advocacy for patient-centric policies crucial in addressing pressing healthcare issues.

Healthcare Reform Considerations

  • Overview of significant laws and legislation impacting healthcare delivery, notably the Patient Protection and Affordable Care Act (ACA).
  • Emphasizes the ongoing challenges of expanding access to affordable healthcare for all.