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  1. Ethics Topic 03 Ethics Theories Principles Resolving ethical dilemmas – models of decision making Discontinuing treatment Not for resuscitations

  2. Controlling Unpredictability of health Ethics

  3. Principle Based Ethics • Autonomy • Beneficence • Non-malificence • Justice

  4. 1. Principle of Autonomy • Humans have the right to non – interference when making decisions about themselves • Free will , without any pressure ??? • Health information asymmetry • Forms the basis of ideas about privacy, confidentiality, veracity, fidelity and consent

  5. a. Confidentiality • Not reveling information collected from the patient: • Verbally • Examination • Records • Complicated process • Educate staff • Security of Medical documents

  6. b. Privacy • Areas where patient does not want to reveal : • History • Examinations • Complicated process: • Social harm • Social benefit • Use your common sense

  7. c.Veracity • Revealing truthful information to the patient: • As a professional • Cultural /social /Medical • harm • Benefit

  8. d. Fidelity • Practicing within the boundaries of Nursing • Scope of practice • Professional standards

  9. e. Consent • Intervention • Wiliness to agree to undergo any intervention • Implied • Verbal • Written

  10. 2. Principle of Beneficence • “I will use treatment for the benefit of the sick, according to my ability and judgment” Hippocratic Oath • Conduct is aimed at the good and well being of others • Principle requires that practitioners provide both appropriate treatment and an assurance that the treatment will not produce more harm than good

  11. 3. Principle of Non-malificence • “Above all do no harm” -Hippocratic Oath • In health care the ethical issues of non-malificence and beneficence are particularly apparent in decisions regarding the institution of dangerous therapy or withdrawal of therapy that is no longer thought to be beneficial.

  12. 4. Principle of Justice • Justice as fairness • Comparative Justice • Distributive Justice


  14. Identify the ethical problem • Is it ethically reasonable to allow a person to stop eating and drinking • This situation was complicated by the fact that JD was unable to communicate and may or may not be confused, or in fact mentally competent

  15. Mental competence • We cannot proceed further with solving this ethical question until we decide if JD is mentally competent. • If after examination Mr. D is considered mentally competent and able to communicate then continuing to drip feed him is an unbearable assault on his person and the decision to forgo treatment is straight forward

  16. If JD is not competent • ‘Can we ethically refrain from providing food and fluid to a mentally incompetent individual who appears to have a poor quality of life but will need to be restrained by force to feed him’

  17. What facts are available? Will he be likely to suffer more from not feeding him or restraining him and forcing food upon him?

  18. Consider the four principles • In JD’s case we cannot negotiate fully with him as he is not mentally competent. So in order to respect his autonomy, we must fallback on other ways of dealing with him, such as involving family or close friends, ascertaining whether he has left instructions about what do in this circumstance (advance directives)

  19. Consider the four principles Although we wish to do our best to help him, we are still unsure as to whether he will be best served by being allowed to die or by being forced to live. • Which option will entail the greater burdens? • Which option will afford him and his family the most justice?

  20. There is no single answer • A solution will only be obtained from collaboration within the health team and with others who are close to the patient • Issues of justice, most commonly resource allocation may become important

  21. Identifying ethical conflicts • There is a conflict between the principle of beneficence and non-malificence. • We wish to help this man, but we are unsure if our help will actually harm him

  22. Consider the Law • We need to enquire of relatives whether JD had expressed views about treatment he would have declined. • In this case his wishes should be considered when deciding treatment. • None of the proposed courses of conduct would appear to be deliberating intended to end JD’s life (which would be illegal)

  23. Consider the Law • A court if asked to consider this issue would probably not consider the withdrawal of treatment (artificial nutrition and hydration) to be the primary cause of JD’s death. • In this instance the approach that a legal enquiry would follow would be the similar to that of ethics.

  24. Making the Clinical Decision • Gather all the relevant information and communicate between health professionals, patients, families and between members of the health team. • The decision should be discussed with all concerned and documented clearly in the notes, specifying who was involved in making the decision and why the decision was made.

  25. Making the clinical decision • The decision should be reviewed at intervals as determined by the clinical context. • The decision may be reviewed after the patient has died, by a clinical audit, the coroner, and the legal system • It is important that individual practitioners evaluate their own moral decisions

  26. Clinical Ethics • Since the 1970’s clinical ethics has developed. • Clinical ethics committees have emerged within all institutions • They can assist with promoting and enhancing shared decision making.

  27. Ethics and Nursing • Ethics when applied to nursing is the standard of behaviour which nurses are expected to follow in the interest of the public good • A nursing code of ethics provides nurses with guidelines which the standards of practice for the profession are conceived, preserved and refined.

  28. Code of Ethics for Nurses in Australia • Has been developed for nursing in the Australian context and is relevant to all nurses in all practice settings • The code of ethics outlines the nursing profession’s intention to accept the rights of individuals and to uphold these rights in practice.

  29. Code of Ethics for Nurses in Australia Its purpose is to: • Identify the fundamental moral commitments of the profession • Provide nurses with a basis for professional and self reflection on ethical conduct

  30. Purpose • Act as a guide to ethical practice • Indicate to the community the moral values which nurses can be expected to hold. • The code contains six broad value statements with explanatory notes

  31. Personal Moral Stance • Nurses may adopt a personal moral stance that would make participation in certain procedures morally unacceptable to them. • Nurses have a right to refuse to participate in procedures which they judge on strongly held moral beliefs to be unacceptable, however they must ensure the quality of care and patient safety are not compromised.

  32. A framework for nursing ( 02) • The Code of Ethicsis supported by the Code of Professional Conduct for Nurses in Australia. The Code of Ethics focuses on the ethics and ideals of the profession.

  33. Code of Ethics

  34. Code of EthicsValue statement 1 • Nurses respect individual needs, values, culture and vulnerability in the provision of nursing care

  35. Code of EthicsValue statement 2 • Nurses accept the rights of individuals to make informed choices in relation to their care

  36. Code of EthicsValue Statement 3 • Nurses promote and uphold the provision of quality nursing care for all people

  37. Code of EthicsValue Statement 4 • Nurses hold in confidence any information obtained in a professional capacity, use professional judgment where there is a need to share information for the therapeutic benefit and safety of a person and ensure that privacy is safeguarded

  38. Code of EthicsValue Statement 5 • Nurses fulfill the accountability and responsibility inherent in their roles

  39. Accountability and Responsibility Accountability: the state of being answerable for one’s decisions and actions. It cannot be delegated. Responsibility: the obligation that an individual assumes when undertaking to carry out planned/ delegated functions. The individual who authorizes the delegated function retains accountability

  40. Code of EthicsValue Statement 6 • Nurses value environmental ethics and a social, economic and ecologically sustainable environment that promotes health and well being

  41. Code of Professional Conduct

  42. Code of Professional Conduct • Identifies the minimum requirements for practice in the profession, and focuses on the clarification of professional misconduct and unprofessional conduct. • The two Codes, together with published practice standards, provide a framework for nursing.

  43. The Code of Professional Conduct The purpose of the Code of Professional Conduct for nurses in Australia is to: • Set an expected national standard of conduct for the nursing profession • Inform the community of the standards & • Provide consumer, regulatory, employing and professional bodies with a basis for decisions regarding standards of professional conduct

  44. Code of Professional Conduct A nurse must: • Practice in a safe and competent manner • Practice in accordance with the agreed standards of the profession • Not bring discredit upon the reputation of the nursing profession • Respect the dignity, culture, values and beliefs of an individual and any significant other person

  45. Code of Professional Conduct • Support the health, well being and informed decision making of an individual • Promote and preserve the trust that is inherent in the privileged relationship between a nurse and an individual, and respect both the person and property of that individual

  46. Code of Professional Conduct • Treat personal information obtained in a professional capacity as confidential • Refrain from engaging in exploitation, misinformation and misrepresentation in regard to health care products and nursing services

  47. Competencies • There are professional and ethical competency units within the ANMC Enrolled Nurse Competencies which are endorsed by the Nurses Board. • Enrolled nurses are expected to function in accordance with legislation, policies and procedures affecting nursing practice • They are expected to conduct nursing practice in a way that can be ethically justified

  48. Professional Competence • Professionals are expected to internalise the standards of the profession that guide their day- to- day work

  49. Is it lawful to disguise medication in the patient’s food? • Ethical issues breach of trust????? • Legal issues duty of care????? • Does it matter if it is medication for a physical or psychological ailment? Linda Saunders 7/12/04

  50. Unclear…….. • Should not be a practice adopted to meet time issues associated with inadequate staff levels • Ultimately may meet duty of care • Should be open and transparent • Discuss with next of kin/care team • Formalize as part of the care plan, • Sets a standard of care for that person Linda Saunders 7/12/04