Ethics. Khaled Abdallah Khader King Hussein Cancer Center . What is Ethics?. Common responses: “Ethics has to do with what my feelings tell me is right or wrong.” “Ethics has to do with my religious beliefs.” “Being ethical is doing what the law requires.”
Khaled Abdallah Khader
King Hussein Cancer Center
“Ethics has to do with what my feelings tell me is right or wrong.”
“Ethics has to do with my religious beliefs.”
“Being ethical is doing what the law requires.”
“Ethics consists of the standards of behavior our society accepts.”
“I don’t know what the word means.”
“Raymond Baumhart, Sociologist”
Principles that define behavior as right, good, and proper.
Ethics is about putting principles into action.
Values are inner judgments that concern how a moral person actually behaves.
Values are learned and are greatly influenced by a person’s sociocultural environment (e.g. folk healer, observation and experience)
People need societal values to feel accepted, and they need personal values to produce a sense of individuality.
Professional values often reflect and expand on personal values
Once a person becomes aware of his/her values, they become an internal control for behaviour, thus, a person’s real values are manifested in consistent pattern of behaviour
Nurses acquire these values during socialization into nursing – from codes of ethics, nursing experiences, teachers, and peers.
Watson (1981) outlined 4 important values of nursing:
Strong commitment to service
Belief in the dignity and worth of each person
Commitment to education
Nurses often need to behave in a value-neutral way (i.e. being nonjudgmental)
Nurses need to understand their own values related to moral matters and to use ethical reasoning to determine and explain their moral positions.
Moral principles are also important, otherwise they may give emotional responses which often are not helpful.
Although nurses can not and should not ignore or deny their own and the profession’s values, they need to be able to accept a client’s values and beliefs rather than assume their own are the “right ones”
This acceptance and nonjudgmental approach requires nurses to be aware of their own values and how they influence behaviour
What values you hold about life, health, illness, and death?
How do your values influence the nursing care you provide?
We should explore our own values and beliefs regarding such situations as the following:
An individual’s right to make decisions for self when conflicting with medical advice
The process of becoming more conscious of and naming what one values or considers worthy is known as “value clarification”
In value clarification:
we examine what we believe is good, bad, beautiful, worthy, meaningful, …..and explore the process of determining our personal values.
The purposes of value clarification
To increase our self-awareness or understanding of ourselves and assist us in making choices.
To facilitate decision-making, because we have a better grasp of our own value system.
Consequently, this will be helpful when you are faced with an ethical dilemma
Ethical dilemmas occur when individuals must choose between two unfavorable alternatives “e.g. assisted suicide”
- Occurs when someone else in the health care setting performs an act the nurse believes to be immoral.
- Nurses do not participate in the act.
- Nurses not responsible for what they hold to be wrong but perceive that they are powerless to prevent it.
Ethical dilemmas usually have no perfect solution and those making decisions may find themselves in the position of having to defend their decisions
Value conflict occurs when we must choose between two things, both of which are important to us.
It’s the nurses’ role to help clients identify values and clarify them……
[Such perceptions are based on values]
What to do in such situations?
Principles and rules of right conduct
Private, and personal
Commitment to principles and values is usually defended in daily life
Pertain to an individual‘s character
Formal responding process used to determine right conduct
Professionally and publicly stated
Inquiry or study of principles and values
Process of questioning, and perhaps changing, one’s morals
Speaks to relationships between human beings
Teleology: looks to the consequences of an action in judging whether that action is right or wrong
Deontology: proposes that the morality of a decision is not determined by its consequences. It emphasizes duty, rationality, and obedience to rules
The difference between Teleology and Deontology can be seen when each approach is applied to the issue of abortion.
Teleology approach/abortion: saving the mother’s life (the end, or consequence) justifies the abortion (the mean, or act).
This theory frequently is referred to as
Ethic of caring: it is based on relationships.
End of life issues
Rationing (resource allocation)
Principles of Ethics
The right of self-determination, independence, and freedom. It comes from the Latin auto meaning “self ” and nomy, which means “control.”
Some refer to autonomy as respect for the individual and include the expectations that each individual will be treated as unique and as an equal to every other individual (Davis et al, 1997).
Rooted in Kant’s deontological philosophy.
The ability of human beings to choose for themselves and determine their own course of life.
Writers may refer to it as the Principle of Individual Freedom (Thiroux, 1998).
Other words often associated with autonomy include dignity, inherent worth, self-reliance, and individualism.
Four factors for violations of patient autonomy
• Nurses may assume that patients have the
same values and goals as themselves
• Failure to recognize that individuals’ thought
processes are different
• Assumptions about patients’ knowledge
• Focus on work rather than caring
Requires that we provide benefits to others, and act with concern for what is in their best interest.
The obligation to do good
Rests in the ethical theory of utilitarianism
It also maintains that we ought to prevent evil or harm (Burkhardt & Nathaniel, 1998).
To do no harm (minimizing the harmful effect of interventions).
(the prohibition of intentional harm).
As far back as Hippocrates, physicians were entreated to do no harm.
The obligation to be fair to all people.
Does fairness mean that people should be treated the same? In terms of access to health care, is it “just” for one person to receive more resources than another receives?
The obligation to be faithful to the agreements, commitments, and responsibilities that one has made to oneself and others.
Interestingly, it is one of the ethical concepts not addressed specifically in some textbooks of nursing ethics. Fidelity is the foundation of the concept of accountability that we hear about so often today.
What are the responsibilities of health care personnel to individuals, employers, the government, society, and self?
When these responsibilities conflict, which should take priority? In reality, which do take priority? Are we obligated to provide care to all patients? Under what circumstances, if any, might this be challenged?
Telling the truth or not intentionally deceiving or misleading patients.
As we become adults, we see more and more instances where the choices are less clear. For example, do you tell the truth (veracity) when you know the truth will cause harm to an individual (maleficence vs. nonmaleficence)?
Take a moment to reflect:
Ethical decision making
An act can be:
MORAL model (Thiroux, 1977).
With the increasing complexity of ethical issues in health care, ethics committees have been created to assist in making ethical decisions in clinical settings. Ethical committees can:
1. Provide structure and guidelines for potential problems.
2. Serve as an open forum for discussion and debate.
3. Function in a patient advocate role by placing the patient at the core of the committee’s deliberations.
End of Life Issues
A patient’s ability to make specific decisions regarding his or her own current or future medical care.
DMC requires only that the patient be able to make the single decision in question
Understand and interpret the clinical information being presented
Understand each of the options for treatment or non-treatment and the consequences of each choice
Make and communicate a choice
Use a rational thought processes in considering personal values and experiences as they relate to the options being presented
Patients are informed of their right to accept or refuse care and make advance directives
The Act is intended to protect the views and choices of patients when they become decisionally incapacitated.
Includes Living Wills & Durable Power of Attorney for Health Care
Prepared while patient has decisional capacity
Describes patient preferences in the event they become incapable of making decisions or communicating decisions.
Usually describes what type of life prolonging procedures the patient would or would not want and circumstances under which they would want these procedures carried out, withheld, or withdrawn.
Reviewing the patient's medical records
Consulting with the health care providers
Applying for medical benefits on the patient’s behalf
Making life prolongation/terminating decisions if the surrogate form meets the requirements of the living will statute.
Healthcare professionals may find it difficult to stop life-sustaining treatment because they have been trained to do everything possible to support life.
Withdrawal or withholding treatment is a decision/action that allows the disease to progress on its natural course. It is not decision/action intended to cause death.
Examples (medically provided hydration/nutrition, ventilation, dialysis)
Confirms no effort will be made to reestablish the heartbeat or breathing of a patient suffering cardiac or respiratory arrest.
A DNR must be written by a physician: (1) at the request of a competent patient,
(2) or according to the patient's Advance Directives,
(3) or at the direction—or with the consent—of the patient's surrogate decision maker.
Complete an advance directive
Address patient misconceptions in the discussion
Facilitate these discussions early in the course of a life threatening illness
Explain that the discussion is important because you wish to understand and honor the patient’s wishes
Revisit the discussion when the patient’s clinical situation changes
Assisted suicide occurs when another provides a means with knowledge of the patient’s intent to use it to commit suicide.
Requests may signify crisis, unrelieved suffering or a plea for help
Invites physical, emotional, spiritual, psychosocial assessment and interventions
Greek words meaning “easy death”.
Euthanasia is an act by which the causative agent of death is administered by another with the intent to end life.
Killing an innocent person, even at his or her request is not ethical.
“Code for Nurses (1985) and the ANA position statement (1994) states that the nurse should not participate in euthanasia but be vigilant advocates for the delivery of dignified and human care.
Mr. Smith is so overwhelmed at his beloved father's suffering that he decides to do whatever he has to do to end it. He administers a massive overdose of his father's pain medication, with the intention of causing his father's death, and thereby releasing him from his suffering.
Interventions that will lead to no useful result
Conflicts: benefit/burden of treatment
Treatment is ethically futile if it will not serve the underlying interests of the patient.
Institutions have developed futility polices to assist in determining when a treatment is futile.
Mrs. Anderson is terminally ill, and death is imminent for both. Mrs. Anderson’s family has been gathered around her bedside for several days, and she has said her goodbyes. She has also received the Sacrament of the Sick. When he breathing begins to be labored, one of her sons asks if she should put on a ventilator. After discussion with her physicians Mrs/ Anderson decides that would only prolong he death, which she says would serve no purpose. She asks only for sufficient pain medication to control her pain, and accepts death.
Begin by asking the patient/family to explain their understanding of the current situation.
Identify the goals of care for the patient
Begin by suggesting what interventions would be helpful in achieving the patient’s goals of care
Suggest what interventions may not be helpful in achieving the patient’s goals of care
“ An informed decision is one where a reasonable choice is made by a reasonable individual using relevant information about the advantages and disadvantages of all the possible courses of action, in accord with the individual's beliefs”.
The voluntary consent of the human subject is absolutely essential. Nuremberg Code
For all biomedical research involving human subjects, the investigator must obtain the informed consent of the prospective subject…or authorized representative. CIOMS guidelines
Disclosure of information
Voluntary decision making