2513 week 1 notes

Textbook- Concepts and Cases in Nursing Ethics

• The profession of nursing and the health care system are undergoing rapid development.

• New and diverse roles are emerging, while old roles are being redefined.

• The profession is becoming more reflective about the meaning of nursing:

  • Questions posed include: What is nursing?, What ought nursing to be?

  • These inquiries are intricately bound up with ethics.

• The aim of this book is to present a unified perspective on the ethical dimension of contemporary nursing.

• Its objective is to furnish nurses with a clearer understanding of:

  • Key concepts and arguments related to ethical issues in nursing.

  • This understanding will better equip nurses to face challenges and to practice responsibly in their chosen fields and specialties.

• The book is organized into eight main chapters and an addendum:

  • The first chapter serves as a primer on ethical analysis and core principles of ethical theory.

  • Chapters 2 through 7 elucidate six fundamental concepts essential to ethical analysis and theory:

    • Beneficence (doing good)

    • Autonomy (respecting individuals' rights)

    • Truthfulness (honesty in practice)

    • Privacy and confidentiality (protecting patient information)

    • Justice (fairness in care)

    • Integrity (professional honesty and ethics)

  • Each concept embodies a value, principle, or virtue esteemed in nursing and broader health care.

• Ethical norms and guidance from professional nursing associations and regulatory bodies are referenced throughout, as well as legal frameworks relevant to nursing practice.

• This edition includes:

  • A chapter specifically addressing end-of-life care.

  • Discussions on palliative care developments and MAID allowing for detailed ethical analysis in practice implications.

• An Addendum reflecting on the COVID-19 pandemic in relation to the main value concepts presented in the book.

• Each chapter features cases for reflection or discussion highlighting issues pertinent to the chapter's concept:

  • Cases might be compiled from publicly available information, landmark court cases, or fictionalized based on authors’ personal experiences.

  • Cases are introduced with a preamble providing context and often followed by critical commentary for ethical analysis; some cases encourage independent analysis from readers.

• Chapters are sequential yet stand-alone, allowing readers to select based on individual interests.

• The book aims to serve as a comprehensive resource for a dedicated course in ethics or for instructors seeking relevant chapters in alignment with their curriculum topics.

• The authors hope that practicing nurses and nurse educators find this book beneficial for facilitating reflection and conversation on various ethical issues encountered in health care settings.

WHAT IS NURSING ETHICS?

• Nursing ethics can have multiple meanings:

  • In one sense, it refers to the expressed moral norms of the nursing profession:

    • Includes values, virtues, and principles that guide nurses in everyday practice.

    • Typically articulated as moral injunctions, such as:

      • "Be truthful with patients"

      • "Respect patient confidentiality"

  • Norms may also encourage the adoption of specific virtues, such as:

    • Caring

    • Fairness

  • These norms are publicly stated in codes of ethics, serving dual purposes:

    • To guide nurses in their practice and identity formation.

    • To inform the public expectations regarding professional practitioners.

• In another sense, nursing ethics encompasses a body of scholarship and research:

  • Involves literature found in books and professional journals that focus on the moral dimension of nursing.

  • This aspect analyzes, discusses, and debates various ethical issues.

  • In this context, nursing ethics refers to the field or discipline where norms are critically examined and debated.

NURSING ETHICS, BIOETHICS, HEALTH CARE ETHICS

• Nursing Ethics Development:

  • Evolved alongside bioethics and health care ethics.

• Bioethics Definition:

  • Reasoned enquiry regarding the ethical dimension of interventions affecting human health.

  • Affects individuals and the collective good.

• Health Care Ethics:

  • Sometimes used interchangeably with bioethics, notably concerning interventions in health.

• Scope of Bioethics:

  • Includes research and experimentation involving ethical considerations.

• Emergence Influencing Factors:

  • Three noteworthy factors have played a significant role in the rise of contemporary bioethics, influencing both health care ethics and nursing ethics (Rodney, Burgess, et al., 2013):

    • [List the three factors that will be further discussed]

Technological Developments

• Rapid Scientific and Technological Developments:

  • Introduced new powers and treatment options for health professionals.

  • Created new ethical issues that need to be addressed.

• Example of Ventilators:

  • Enabled the prolongation of life (or death).

  • Raised difficult ethical questions regarding their use.

• Other Areas of Concern:

  • Reproductive technology: Ethical considerations surrounding assisted reproductive methods.

  • Transplantation: Ethical dilemmas related to organ donation and recipient selection.

  • Genetics: Complex ethical issues arising from genetic testing and manipulation.

• Technological Developments vs. Ethical Norms:

  • Technological changes outpace the capacity of existing ethical norms.

  • Result in confusing grey areas that require consensus through dialogue and debate.

• Role of Scholars:

  • Ethicists, philosophers, nurses, physicians, and other healthcare providers work to:

    • Think critically and systematically about ethical issues.

    • Address difficult grey areas using emerging evidence.

• Contribution to Healthcare:

  • Such academic work aims to improve health and healthcare for individuals, groups, and society overall.

Research and Experimentation

• Negative Publicity: The negative publicity regarding gross abuses in research involving human subjects during Nazi Germany and questionable research practices in North America sparked significant discussion about ethics in research (Beecher, 1966, 1959).

• Exclusion of Categories: Should certain categories of people, such as:

  • Children

  • Captive populations

  • Individuals lacking mental capacity to make decisionsbe excluded from research?

• Voluntariness of Participants: What measures and controls can best ensure the voluntariness of research subjects?

• Benefit vs. Harm Ratios: How do we determine acceptable ratios of benefit to harm, and who should be responsible for making these decisions?

• Principles of Bioethics: Many key principles of bioethics, such as:

  • Informed consent

  • Autonomy

  • Beneficencehave been developed and modified in response to these ethical considerations.

• Progress in Standards: Over time, there has been significant progress in the standards and applications of both research ethics and bioethics.

Consumerism and Patients’ Rights

• 1960s North America: Emergence of consumer education and protection.

  • Ethical discussions increasingly featured the rhetoric of rights (Fleming, 1983; Storch, 1982).

  • Health care system scrutinized as a locus of considerable power.

• Patient Empowerment:

  • Patients began viewing themselves as consumers.

  • Demanded a more active and controlling role in their own care.

• Key Event:

  • In 1973, the American Hospital Association introduced a twelve-point “Patients’ Bill of Rights”.

  • This was implemented in various American and Canadian institutions.

• Patients’ Rights Movement:

  • Coincided with rising public distrust of authority figures (religion, government, scientists, professionals).

  • Increased scrutiny of health professionals led to higher standards of public accountability.

• Shift in Ethical Discourse:

  • Ethical issues traditionally managed by professionals became public questions.

  • Emergence of a new ethic centered on “autonomy”.

• Cultural and Political Context:

  • Growth of cultural and political pluralism valuing individual rights and liberties.

  • Traditional paternalism within health professions faced widespread criticism.

• Patient Involvement in Decision-Making:

  • Patients increasingly demanded inclusion in the decision-making surrounding their health care.

• Legislative Changes:

  • Reflective of and responsive to new public expectations about patient involvement, exemplified by the doctrine of informed consent.

• Emerging Ethical Issues:

  • Public consensus on health care ethics strained as new ethical dilemmas arose.

  • Long-standing ethical issues took on new urgency as they were re-examined.

• Development of Contemporary Bioethics:

  • This environment enabled questioning that fostered the development of contemporary bioethics.

  • Professional philosophers and theologians applied their expertise to emerging ethical concerns.

  • Health professionals grew more interested in moral philosophy and moral reasoning within their practice.

NURSING ETHICS AND NURSING

• Gender Dynamics in Nursing:

  • Predominantly a woman’s profession, though the gender balance is shifting.

  • Some authors argue that women value nurturing and caring more, leading to an "ethic of care" being particularly apt for nursing.

  • This viewpoint is debatable and will be explored further in Chapter 2.

• Caring vs. Curing:

  • Nursing tends to focus on "caring" rather than just "curing".

  • The understanding of health in nursing is generally broader than that in medicine, affecting how ethical issues are framed.

• Perception of Nursing:

  • Society's value placed on nursing work impacts the drive for professionalism within the field.

  • Historically, nursing has faced subordination in the health care system.

    • Example: The motto of the Mack training school for Nurses was: “I see and am silent” (Coburn, 1987).

• Power Dynamics:

  • Legal and institutional constraints limit many nurses' ability to practice ethically (Yarling & McElmurry, 1986).

  • Organizational constraints and the distribution of power shape the ethical challenges nurses encounter in daily practice (Rodney et al., 2013; Varcoe & Rodney, 2009).

• Multiple Obligations:

  • Ethical issues often arise from nurses facing multiple obligations within institutional settings.

  • Despite the rise of interprofessionalism and collaboration, nurses may deal with decisions they did not influence and disagree with.

• Advocacy for Ethical Practices:

  • Nursing emphasizes the importance of nurses taking proactive steps to create ethical practice environments.

• "Being There" in Nursing:

  • Storch labeled this as an essential aspect of nursing ethics (1988): nursing is less episodic compared to other health professionals.

  • Nurses provide continuous care, being present for patients around the clock.

    • Physicians may make episodic visits, while nurses witness the full patient journey.

  • This continuous contact allows nurses to develop a deeper understanding of patients and their distress, impacting ethical considerations in care provision.

MODELS OF THE NURSE-PATIENT RELATIONSHIP

• The ethical landscape of nursing varies based on the viewpoint of the relationship between nurse and patient.

• There are three main models to consider when thinking about this relationship:

  • Contractual Model:

    • Focuses on the negotiation of moral parameters through dialogue between nurse and patient.

    • Establishes explicit expectations and involvement in care planning.

    • Promotes trust and empowerment for the patient, offering a sense of control during distressing times.

    • The shift from using "patient" to "client" emphasizes autonomy and collaboration.

  • Patient Advocate Model:

    • Nursing embraces the role of advocacy more than other health professions.

    • Involves educating patients about their rights and standing up for their interests.

    • Particularly important for vulnerable patients who may struggle to advocate for themselves.

    • Addresses the risks of paternalism in healthcare, ensuring the patient’s voice is heard.

    • Critique: Risks reducing patients to one-dimensional "rights-bearers" instead of acknowledging their full humanity.

  • Social Justice Advocacy Model:

    • Recognizes the collaborative nature of nursing practice and the broader social context of care.

    • Nurses advocate not just for individuals, but also for families and communities.

    • Emphasizes system-level issues that affect access and quality of care.

    • Expands advocacy to include social and political action for social justice and human rights.

The Contractual Model

• Contractual Model: In this model, the nurse and the patient engage in a dialogue to negotiate the moral parameters of their relationship.

  • The dialogue clarifies the expectations of each party.

  • Key questions to address include:

    • Special Values: Does either the nurse or patient possess any special values that may impact the relationship?

    • Patient Involvement: How much does the patient wish to participate in care planning?

    • Consultation: Which family members or friends should be consulted if necessary?

  • During discussions, either party may discover unacceptable expectations or demands from the other.

  • It is essential to identify these discrepancies before any issues arise.

  • The shared understanding developed through negotiation acts as a “contract” guiding ethical decision-making within the relationship.

  • This understanding fosters trust, as both parties know what to expect from one another.

  • It also empowers the patient by providing a sense of control during disorienting times such as illness and unfamiliar environments.

  • The preference for using the term “client” instead of “patient” aligns with the empowering spirit of the contractual model, emphasizing the agency of the client/patient and the voluntary nature of the relationship.

The Patient Advocate Model

• Patient Advocate Role in Nursing:

  • The concept of the patient/client advocate has been widely embraced by nursing, more so than by other health professions.

  • The term "advocate" originates from law and gained prominence with the rise of consumerism and the patients' rights movement in health care.

• Advocacy in Health Care:

  • Advocacy in this context typically refers to defending patients' rights, which includes:

    • The right to be informed about treatment options.

    • The right to access personal health records.

  • Many patients may be unaware of their rights; in these instances, advocacy involves:

    • Informing or educating patients regarding their rights.

• Acting on Behalf of Patients:

  • When patients' rights are ignored or overlooked, advocacy can involve:

    • Defending the patient's rights and interests with colleagues or institutional bodies.

  • This role is especially crucial for vulnerable patients, who may be:

    • Overwhelmed by their health condition.

    • In unfamiliar, institutional settings.

    • Incapable of expressing their needs or advocating for themselves.

• Importance of Rights-Based Advocacy:

  • The rights-based advocacy model holds significant value in nursing as it acts as a corrective when:

    • Patient autonomy is threatened by paternalism (the imposition of beliefs by others regarding what is best for the patient).

    • The patient might be overlooked within the healthcare system.

• Critiques of Rights-Based Advocacy:

  • There are shortcomings in focusing primarily on rights, such as:

    • It may overshadow other vital aspects of the patient's experience.

  • Gadow (1980) criticized this model for depicting patients in a one-dimensional, abstract way that reduces them to mere bearers of rights.

  • Instead, Gadow advocated for "existential advocacy," focusing on the whole patient as a complete being, rather than just their rights.

The Social Justice Advocacy Model

• One-to-One Models: The presented models are based on a one-to-one relationship between a nurse and an individual patient.

• Limitations of the Models:

  • While these models highlight important dimensions of nursing roles, they do not encompass the full scope of nursing practice.

  • They overlook the fact that nurses typically collaborate with other nurses and health professionals.

• Collaborative Relationships:

  • Such collaborations can complicate a nurse's relationship with patients.

  • In public health, nurses may advocate for a family or community rather than a single patient.

• Broader Social Contexts:

  • The models fail to reflect the roles that nurses play in addressing system-level issues affecting access to care and quality of care.

  • Nurses also focus on the health of populations rather than just individuals.

• Emerging Roles:

  • There is an increasing emphasis on the roles of nurses in tackling system-level issues related to healthcare delivery.

  • Many nurses now see their roles as extending beyond patient advocacy to include social and political action toward social justice and human rights.

A KNOWLEDGE BASE IN ETHICS FOR NURSING

Knowledge Base in Ethics for Nursing

• Contextual Development: Understanding the context in which contemporary nursing ethics has developed is essential for practicing nurses.

• Focus on Individual Practice: What does this context imply for individual nurses in their day-to-day practice?

Areas of Knowledge and Reflection in Nursing Ethics

There is consensus in nursing ethics literature on at least three main areas of knowledge and reflection:

1. Moral Beliefs and Values

   • Nurses should recognize their own moral beliefs and how these values affect their practice.

   • Understanding personal values is essential to navigate ethical dilemmas and patient care considerations.

2. Relevant Codes, Policies, and Laws

   • Nurses should be familiar with codified ethics including:

     • Codes of ethics from professional associations.

     • Institutional policies and protocols guiding nursing practice.

     • Legal norms that bear on practice and influence ethical decision-making.

   • Codes and policies provide guidance, but do not replace the need for ethical reasoning and accountability.

3. Fundamental Concepts of Moral Philosophy

   • Nurses need a basic understanding of ethical theories and fundamental concepts to analyze ethical issues effectively.

   • Important foundational concepts include:

     • Beneficence: The obligation to do good for patients.

     • Autonomy: Respecting patients' rights to make decisions.

     • Integrity: Upholding professional honesty and ethics.

     • Justice: Ensuring fairness in patient care.

     • Confidentiality: Protecting patient information.

     • Truthfulness: Being honest in practice and communication.

Moral Beliefs and Values

• Upbringing and Acculturation:

  • Influences from family, peers, and societal norms shape our beliefs about right and wrong, and good and bad.

  • These beliefs become a fundamental part of our identity as adults and can influence our actions unconsciously.

  • Often, we only become aware of these beliefs when they are challenged by others.

• Ethical Commitment:

  • Living an ethical life involves bringing unexamined beliefs to conscious awareness.

  • It requires individuals to clarify their beliefs and responsibly embrace, reject, or modify them.

• Values Clarification:

  • This is the process of increasing awareness and reflection on our values, shaped by various influences.

  • Enables self-conscious decision-making regarding which values to promote and prize.

  • Important for assessing how personal and professional practices relate to these values.

• Professional Identity in Nursing:

  • Nurses must shape their professional identities according to the ethical values of the nursing profession.

  • Intervention in the lives of others carries significant responsibility and is often legitimized in healthcare contexts.

• Primary Value in Healthcare:

  • Health is the most critical value within the healthcare context.

  • However, this can conflict with other important values like autonomy, truthfulness, confidentiality, and justice.

• Navigating Value Conflicts:

  • Nurses must develop sensitivity to the values dimension within nursing practice.

  • At each step of the nursing process, questions of value should be considered, such as: "Are there any questions of value to be considered here?"

• Complexity of Ethical Issues:

  • Although not every nursing action will involve an explicit ethical decision, all nursing acts can potentially promote or transgress some good or value.

  • The values dimension of nursing encompasses complex ethical dilemmas where different values may conflict.

  • Many situations may present ethical concerns that do not necessarily lead to crises or dilemmas.

• Essentials for Ethical Practice:

  • Knowledge of personal values and sensitivity to the values of others, along with related professional values, are crucial for responsible and ethical nursing practice.

Relevant Codes, Policies, and Laws

• A knowledge base in ethics for nursing includes:

  • Codified ethics:

    • Codes, policies, and laws as they relate to nursing practice.

    • Comprises codes of ethics and various guidance documents from professional associations and regulatory bodies.

  • Familiarity: Nurses should be familiar with:

    • Relevant policies and protocols provided by their institutions.

    • Current laws impacting nursing practice.

  • Importance of ethical decision-making:

    • Codes, policies, and laws cannot replace or negate the need for ethical reasoning.

    • These documents may be vague or silent on numerous ethical dilemmas life nurses encounter.

    • Relying solely on legal mandates fails to address the moral appropriateness of actions.

  • Defending decisions: Ethics requires providing reasons to justify decisions, including choices to follow or reject specific codes or laws.

  • Non-absoluteness of codified ethics:

    • Actions may be legal yet unethical or conversely, illegal actions may be ethically permissible based on some value systems.

  • Impact of changing laws and social norms:

    • Evolution of laws (e.g. MAID) shows that societal views change over time.

  • Starting point for reflection: Ethical codes, policies, and laws serve as initiation points for discussing ethical issues but do not resolve them definitively.

    • They embody collective wisdom of the profession, institution, and community.

  • Considering codified ethics is crucial:

    • Arriving at different conclusions without engaging with ethical guidelines is seen as arrogant.

  • Consequences of non-compliance: Ignoring ethical guidelines may lead to serious repercussions and should be carefully considered.

  • Positive support: Ethical guidelines can be beneficial, providing backing for nurses facing ethical dilemmas and helping reduce uncertainty in practice.

Ethical Theories and Fundamental Concepts

• Ethical Theory: A dedicated branch of philosophy focusing on ethical theories, which includes both applied and professional ethics.

• Purpose of Ethical Theory: These disciplines are essential for addressing practical issues that arise within various professions, ensuring that professionals like nurses understand the ethical implications of their work.

• Nurses' Knowledge Requirement: It is essential for nurses to possess at least rudimentary knowledge of key theoretical inquiries in ethics.

• Primer on Ethical Theory: This book includes a primer that introduces foundational concepts relevant to ethical analysis specifically for nursing practice.

• Fundamental Ethical Concepts: Nurses should be skilled in using the six foundational concepts to effectively:

  • Identify ethical issues

  • Describe ethical dilemmas

  • Analyze scenarios in nursing practice

• Six Foundational Concepts: The concepts forming the core framework of this text are:

  • Beneficence: The obligation to do good for patients.

  • Autonomy: Respecting patients' rights to make their own decisions.

  • Truthfulness: The importance of honesty in practice.

  • Confidentiality: Safeguarding patients' private information.

  • Justice: Ensuring fairness and equity in patient care.

  • Integrity: Upholding ethical standards and professional honesty.

• Integration into Nursing Language: These concepts are commonly understood in nursing, meaning education involves building upon existing knowledge rather than starting from scratch.

• Common-Sense Usage Issues: The everyday interpretations of these moral concepts can be:

  • Often vague

  • Sometimes contradictory

• Moral Disagreements: Disputes in ethical discussions often arise because individuals interpret terms differently, leading to cross-purposes in communication.

• Philosophical Understanding: A deeper philosophical awareness of ethical concepts allows for:

  • Sorting out confusions

  • Clarifying disagreements

  • Promoting creative problem-solving

• Commitment to Self-Examination: This understanding is vital for nurses in their continuous self-reflection and desire to do what it is.

The Task of Reflection

• The three subject areas that create a solid foundation for ethics in nursing include:

  • Moral beliefs and values

  • Relevant codes, policies, and laws

  • Main ethical theories and fundamental concepts

• Acquiring knowledge is not equivalent to becoming virtuous; rather, the acquisition of knowledge can be considered a virtue in itself.

• Being adept in processes such as:

  • Values clarification

  • Understanding relevant ethical codes, policies, and laws

  • Familiarity with nursing ethics literature and moral philosophydoes not guarantee that individuals will act with virtue.

• A person may be well-informed about ethics but still exhibit insensitivity or even cruelty.

• Conversely, an individual may show kindness but lack knowledge of ethical concepts and moral reasoning.

• Nonetheless, becoming more reflective on the ethical knowledge related to nursing can aid in cultivating the virtues essential for nursing practice. Reflection can assist nurses in:

  • Enhancing their sensitivity to the ethical dimension of nursing.

  • Recognizing and identifying ethical issues when they arise.

  • Analyzing ethical issues more thoroughly by:

    • Describing the main arguments associated with different sides of a given issue.

    • Applying relevant concepts and principles in decision-making.

• The moral life is perceived as a task and a challenge, with the nature of this task varying based on individual life contexts.

• This book is tailored for nursing professionals who encounter specific ethical dilemmas unique to their field.

• Developing a professional identity in nursing involves deepening one’s comprehension of the ethical dimensions inherent to the profession.

• A primary objective of this book is to promote the development and refinement of this understanding.

• The moral task for nurses encompasses not only knowing but also doing and becoming.

• The true benefit of knowledge stems from the subsequent actions taken by the reader, right at this moment.

ETHICAL ANALYSIS AND THE NURSING PROCESS

• Conflicts of Values in Nursing: In the field of healthcare, it is common for conflicts of value to arise during nursing practice.

  • The beliefs and values involved may include those of:

    • The Nurse: Individual ethical standards and personal beliefs.

    • The Profession: Standards and norms established within the nursing field.

    • The Patient: Individual health beliefs and personal values.

    • Family and Friends: Influences and values from the patient’s close network.

    • Other Health Professionals: Values held by interdisciplinary team members.

    • Society: Broader societal beliefs and cultural values.

• Emergence of Ethical Conflicts: Sometimes the values of all parties may not align, leading to ethical conflicts.

  • Ethical life lacks a mechanical formula for resolving these conflicts.

  • Understanding the values dimension of a situation, alongside relevant codes and main ethical concepts, aids in navigating these conflicts more effectively.

• Proactive Intervention: It is crucial to recognize that significant ethical problems often start as minor issues.

  • Early identification and intervention can often prevent escalation.

• Vigilance in Values: Nurses should be proactive in questioning and discussing values in their daily practice.

• Components of Ethical Analysis: Three interrelated components are essential to ethical analysis:

  1. Descriptive Analysis:

     • Focuses on gathering adequate information regarding the situation.

     • Questions to ask include:

       • What is happening in the given situation?

       • What facts are relevant to the ethical decision-making?

       • What information is known for informed decision-making?

  2. Conceptual Analysis:

     • Clarifies the meanings of key concepts relevant to ethical analysis.

     • Important to understand varying interpretations of terms such as “quality of life,” “euthanasia,” and “rights.”

     • The aim is to unpack vague terms and recognize their value-laden implications.

  3. Normative Analysis:

     • Concentrates on determining what ought to be done in the situation.

     • Key considerations include:

       • What moral values are in conflict?

       • Who should be involved in the decision-making process?

       • What are the available options and their ethical implications?

• Integration in Nursing Process: All aspects of ethical analysis should be woven into the nursing process to ensure informed and responsible decision-making in practice.

Assessment

• Recognizing Ethical Issues:

  • One of the most crucial challenges in ethical analysis is acknowledging when an issue has an ethical dimension.

  • Ethical problems can often go unrecognized if individuals fail to see the situation as tied to ethics or values.

  • According to Storch et al. (2009), recognizing the ethical dimension is often the necessary first step in ethical discussions.

  • Example: A situation arises when new physicians refuse to wear identity badges, yet nurses may dismiss this as "not being about ethics."

• Developing Sensitivity to Ethical Issues:

  • Increased familiarity with ethical concepts is vital for nurses to recognize issues that might otherwise go unnoticed.

  • Ethical analysis only commences once an issue has been identified as ethical.

• Assessing and Interpreting Ethical Issues:

  • After identifying an ethical issue, the next step is to make a reasonable assessment of that issue.

  • Initial interpretations may be vague, incomplete, or even false.

• Questions for Deepening Interpretation:

  • What is the exact issue at hand?

  • Is it truly an ethical issue?

  • What type of ethical issue is it?

  • What ethical concepts are involved?

  • What are the relevant facts? Are these clearly understood?

  • What additional information might be necessary?

  • What is the context in which this issue has arisen?

  • What guidance can be derived from the institution’s mission statement, relevant policies, or professional codes of ethics?

  • What values are at stake, and whose values are they?

  • Who are the key individuals involved, and how do they interpret the issue?

  • Is there freedom of expression among parties, or is any coercion present?

• Communication and Value Clarity:

  • Engaging in discussions with others can illuminate misunderstandings or communication gaps that contribute to ethical dilemmas.

  • Clarity about one’s own values is crucial and may warrant reflection during such inquiries.

  • Often, true understanding of personal values emerges only when faced with real-life ethical challenges, prompting moments of reflection and self-discovery.

• Pre-emptive Value Reflection:

  • It is beneficial to think about and decide on values beforehand to navigate ethical situations successfully.

Planning

• Identify and Plan Options: After reaching a reasonable interpretation of the situation, the second step involves identifying and planning the options available.

  • Explore Alternatives: What are the potential alternatives to consider?

  • Support for Options: Determine who supports which option and the reasons behind their support.

  • Arguments for and Against: Identify the main arguments in favor of and against each option.

  • Consideration of Relevant People: Ensure that all relevant individuals have been acknowledged in the decision-making process.

  • Input of Participants: Reflect on how much input each person involved should have in the discussion.

  • Involvement of Stakeholders: Identify who ought to be involved in the decision-making process.

  • Understanding of Options: Confirm whether all involved parties comprehend the options available to them.

• Weighing Options: After sorting through the options, the next task is to weigh them and select the one that is deemed morally best.

  • Promotion of Values: Some options may better promote specific values compared to others.

  • Decision Difficulty: In certain cases, one option may heavily outweigh others, making the decision straightforward.

  • Conflicting Values: Conversely, there may be situations where two or more options are evaluated against conflicting values, leading to a more difficult or even anguishing

Implementation

• Implementation Decisions: Upon selecting an option, it is crucial to consider several key inquiries to ensure that the implementation is carried out in a sensitive and effective manner:

  • Understanding of the Rationale: Do the relevant parties comprehend the reasons for choosing this particular option?

  • Stakeholder Involvement: Who should actively participate in the implementation process?

  • Expected Effects: What effects are anticipated once this option is executed?

  • Management of Consequences: To what extent can the consequences be anticipated and managed, especially to avoid negative outcomes?

  • Flexibility in Planning: Be prepared to adapt the planned course of action based on feedback received during the implementation, particularly if unforeseen complications arise.

Evaluation

• Review the Implementation: After implementing a selected option, conduct a thorough review of the process to assess its effectiveness and outcomes.

  • Evaluate Outcomes: Observe how things are functioning in relation to expectations.

  • Gauge Feedback: Collect feedback from all parties involved, particularly the patient, regarding their feelings about the outcomes.

• Broader Implications: Consider whether the issue has wider implications that may affect institutional policies or practices.

• Future Management: Identify strategies that could enhance the management of similar issues in the future.

• Process Evaluation: Critically assess whether the decision-making process was effective and appropriate.

  • Are there areas for improvement in procedural mechanisms that could enhance future decision-making?

Usefulness of Frameworks for Ethical Analysis and Decision-Making

• Incorporating Ethics into Nursing Practice:

  • Integrating ethics into the nursing process ensures ethical practice within the healthcare setting.

  • It serves as a framework for effectively analyzing and addressing ethical issues that may arise in clinical practice.

• Alternative Frameworks for Moral Reasoning:

  • Various frameworks exist to assist nurses in moral reasoning and decision-making processes.

  • While these frameworks may differ, they generally converge on essential elements of ethical practice.

• Importance of Inquiry:

  • The critical aspect of utilizing any ethical framework is to ask relevant questions that need exploration.

  • Engaging in inquiry fosters a deeper understanding of the ethical dimensions associated with nursing practice.

• Role of Judgment in Decision-Making:

  • Decision-making in nursing is inherently tied to judgment.

  • The effectiveness of any ethical framework is contingent upon the nurse's ability to exercise sound judgment in real-world situations.

CASE-BASED LEARNING

• Intended Audience:

  • The book targets diverse groups, including:

    • Nursing students: Individuals in the process of acquiring nursing education.

    • Nurse educators: Professionals responsible for teaching ethics in nursing.

    • Practicing nurses: Those currently working in the nursing field seeking to enhance their ethical understanding.

    • Students or practicing members of other health professions: Individuals from various healthcare backgrounds looking for ethical insights.

• Case Method:

  • This book utilizes a case method, recognized as an effective approach for:

    • Learning about ethics.

    • Developing one’s professional identity in nursing.

  • Cases serve to demonstrate the application of ethical concepts and tools in practical situations.

  • Engaging with cases makes discussions more lively compared to abstract theories of ethics.

• Educational Strategies:

  • Two primary strategies for using cases effectively in education:

    1. Role Playing:

       • Encourages deeper comprehension of competing perspectives and their supporting arguments.

       • Helps explore various viewpoints, including the initial ones presented in each case.

    2. Classical Debate Format:

       • Learners take on different sides of an ethical dilemma, promoting critical thinking.

       • Particularly useful for issues that are genuine dilemmas where opinions may vary.

       • Introduces the devil’s advocate role to present less popular or weaker positions.

• Facilitating Discussion:

  • A variety of techniques can enhance the effectiveness of discussions:

    • Varying Case Facts:

      • Altering the scenario (e.g., changing location from hospital to home, adjusting patient details, modifying demographics) to gain fresh insights.

    • Imagining Similar Cases:

      • Reflecting on analogous cases aids in flexibility regarding the concepts being discussed.

• Integration of Experience:

  • Essential to connect the case scenarios or the ethical issues addressed to one’s personal experiences.

  • Ethical analysis becomes more meaningful when learned concepts are applied to real-life practice.

  • The objective is to enhance one’s ability to integrate ethical learning into professional nursing practice.

• Focus of Future Chapters:

  • Subsequent chapters will provide both theoretical and practical guidance for ethical nursing practice