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Chapter 4 Ethical Issues

Learning Objectives

1. Define ethics and ethical dilemmas (ATI p 47) (Text 85-86)

2. Compare and contrast the utilitarian, duty-based, rights based and intuitionist frameworks for ethical decision making (Text p 88)

3. Identify and define nine different principles of ethical reasoning (ATI p 47) (Text p 89)

4. Use a systematic problem solving or decision-making model to determine appropriate action for select ethical problems (ATI p 47-48) (Text p 99)

Learning Objectives

5. Describe how differences in personal, organizational, subordinate and patient obligations increase the risk of intrapersonal conflict in ethical decision making. (Text p 94)

Ethical Issues

In an era of markedly limited physical, human, and fiscal resources, nearly all decision making by nurse-managers involves some ethical component. Multiple advocacy roles and accountability to the profession further increase the likelihood that managers will be faced with ethical dilemmas in their practice.

Legal and Ethical Are Not the Same! #1

Legal Ethical	Illegal Ethical
Legal Unethical	Illegal Unethical

Legal and Ethical Are Not the Same! #2

Sometimes, it is very difficult to separate legal and ethical issues, although they are not the same. Legal controls are generally clear and philosophically impartial. Ethical controls are much more unclear and individualized.

Ethics #1

The systematic study of what a person’s conduct and actions should be with regard to self, other human beings, and the environment

The justification of what is right or good and the study of what a person’s life and relationships should be, not necessarily what they are

Ethics #2

Nurses are often placed in situations where they are expected to be agents for patients, physicians, and the organization simultaneously, all of which may have conflicting needs, wants, and goals.

Ethics #3

The way a person approaches and solves ethical dilemmas is influenced by his or her values and basic beliefs about the rights, duties, and goals of all human being

Moral Issues Faced by Nurses

Moral indifference: an individual questions why morality in practice is even necessary

Moral uncertainty: an individual is unsure which moral principles or values apply and may even include uncertainty as to what the moral problem is

Moral distress: occurs when the individual knows the right thing to do but organizational constraints make it difficult to take the right course of action

Ethical Dilemma #1

Defined as making a choice between two or more equally undesirable alternatives

Ethical Dilemma #2

Self-awareness is a vital leadership role in ethical decision making, just as it is in so many other aspects of management.

Two Common Approaches to Ethical Decision Making

Deontological—duty-focused normative approach centered on rules from which all action is derived

Teleological—outcome-focused approach that places emphasis on results and protects the interest of the majority

Frameworks for Ethical Decision Making

Utilitarianism

Duty-based reasoning

Rights-based reasoning

Intuitionism

Principles of Ethical Decision Making

Autonomy

Beneficence

Paternalism

Utility

Justice

Truth telling (veracity)

Fidelity

Confidentiality

Autonomy

Promotes self-determination/freedom of choice

Beneficence (Doing Good)

The actions one takes should be done in an effort to promote good.

Paternalism

One individual assumes the right to make decisions for another.

Justice

Seeks fairness

Treats “equals” equally

Treats “unequals” according to their differences

Veracity

The obligation to tell the truth

Fidelity

The need to keep promises

Confidentiality

Keeping privileged information private

Utility

The good of the many outweighs the wants/needs of the individual.

To Make Appropriate Ethical Decisions

The nurse must use a professional approach that eliminates trial and error and focuses on proven decision-making models or problem-solving processes.

Sample Ethical Problem-Solving Processes

Traditional problem-solving process

Nursing process

MORAL decision-making model

The MORAL Decision–Making Model (Crisham, 1985) #1

M—Massage the dilemma.

O—Outline options.

R—Review criteria and resolve.

A—Affirm position and act.

L—Look back. Evaluate the decision making.

The MORAL Decision–Making Model (Crisham, 1985) #2

A common error made by managers in ethical problem solving is using the outcome of the decision as the sole basis for determining the quality of the decision making.

The MORAL Decision–Making Model (Crisham, 1985) #3

If a structured approach to problem solving is used, data gathering is adequate, and multiple alternatives are analyzed, even with a poor outcome, the manager should accept that the best possible decision was made at that time with the information and resources available.

The MORAL Decision–Making Model (Crisham, 1985)

Perhaps the most important thing a manager can do to create an ethical work environment is to role model ethical behavior.

Professional Codes of Ethics

A code of ethics is a set of principles, established by a profession, to guide the individual practitioner.

The first code of ethics for nurses was adopted by the American Nurses Association in 1950 and has been revised six times since then (most recently in 2015).

Professional codes of ethics do not have the power of law. They do, however, function as a guide to the highest standards of ethical practice for nurses.

Strategies to Promote Ethical Behavior as the Norm

Separate legal and ethical issues.

Collaborate through ethics committees.

Use institutional review boards appropriately.

Foster an ethical work environment.