topic 4 Q2

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’s essential nature and what a nurse does or ought to do in practice? Do nurses employ reason along with virtue in the practice of nursing? How?

Biomedical Ethics Biomedical ethics exemplifies a number of ethical principles: beneficence, nonmaleficence, autonomy, veracity, confidentiality, justice, and fidelity Beauchamp & Childress, 2001; Burkhardt & Nathaniel, 2013; Edge & Groves, 1994; MacKinnon & Fiala, 2014; Veatch, 1977). “Ethical principles are basic moral truths that guide deliberation and action” in medicine and nursing and are grounded in ethical theories (see descriptions in this section) (Burkhardt & Nathaniel, 2008, p. 53). Biomedical ethics presuppose the ethical principle of respect for persons (see Codes of Ethics of the American Nurses Association [2001, 2015], Canadian Nurses Association [2008], International Council of Nurses [2006]. Beneficence is to do good and requires nurses to act in ways that benefit or are good for patients. Nurses are obligated to act beneficently—what is morally and legally demanded by nursing’s professional role (Burkhardt & Nathaniel, 2008, 2013). Beneficence or the good in the nursing role and practice is complex in that nurses are required to have scientific, ethical, humanistic, and aesthetic and personal knowledge of and competency in holism: nurse-patient relationships; body, mind, and spiritual well-being of the patient; cultural differences; and how the context (i.e., economic, legal, technological, and political [power issues]) of health-care organizations are integrated into or affect the well-being of patients, family members, or significant others (American Nurses Association, Code of Ethics for Nursing (2015), www.nursingworld.org/codeofethics; Carper, 1978; Leininger, 1991, 1995; Ray, 1989b, 2001, 2006; Ray & Turkel, 2014, 2015). Promoting the well-being of patients under these circumstances requires a type of supererogation or what is known as “above and beyond the call of duty.” It also requires incorporation of virtue and caring ethics (see theories in this section). Nurses must always be alert to medical orders and their own behavior that can contradict beneficent acts. Nonmaleficence is a principle that requires nurses to act in such a way that no deliberate harm, risk of harm, and harm that relates to doing no harm in the wake of doing good. The first principle of the Hippocratic oath of medicine is to do no harm (Burkhardt & Nathaniel, 2008, pp. 60–62). Weighing a potential harm against a potential benefit is a constant ethical reasoning and caring process in nursing. Autonomy means to facilitate the freedom for self-governance or self- organization in patients with the assistance of family members or significant others. Often there is a critique of the principle of autonomy or self-governance in cultures, such as in Native American culture, where decisions are more communally based (Lowe & Nichols, 2014; Smith-Morris, 2007). Allowing choice, working with the patient, family, and community to cocreate what is needed for health and well-being is a primary nursing role. Nurses are to be advocates of the patient through knowledgeable caring, which means that within the principle of autonomy, there should be no coercion, paternalism, thoughtlessness, and deception. Veracity is an ethical principle that relates to telling the truth. “Truthfulness is widely accepted as a universal human virtue….[t]ruth-telling engenders trust” (Burkhardt & Nathaniel, 2008, p. 65). In terms of relational caring, trust is one of the most important ways of being (Hilsenbeck, 2006; Ray, Turkel, & Marino, 2002).

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Although a relational concept, within the notion of trust there is appreciation for the independent existence of the other and requires “letting go” or the relinquishing of control over the other; “it includes an element of risk and a leap into the unknown, both of which take courage” (Mayeroff, 1971, p. 27) for truth-telling. When there is a perception of mistrust, people hold back on disclosing their secrets or information and the adage of “seeking one’s own counsel” is the actual truth. Veracity in health care requires patience and courage to communicate openly and seek understanding of patient and family needs. Confidentiality is linked with privacy and refers to the right an individual has to personal information or secrets that are disclosed to others, especially health-care professionals. The ethical principle of confidentiality demands that one does not disclose private or secret information about another person with whom one has been entrusted (Burkhardt & Nathaniel, 2008, pp. 66–68; see Health Insurance Portability and Accountability Act [HIPAA], United States, Public Health Law 104-199). Respect for persons is the foundation of the principle of confidentiality. Justice is “the ethical principle that relates to fair, equitable, and appropriate treatment in light of what is due or owed to persons, recognizing that giving to some will deny receipt to others who might otherwise have received these things” (Burkhardt & Nathaniel, 2008, p. 73). Justice issues relate to the distribution of the greatest good to the greatest number. In health care and public health care in particular, the principle focuses on distribution of goods, money, and services (distributive justice). In nations that have a universal healthcare system, the principle of justice in the distribution of health-care goods and services is more equitable than in nations that do not; however, health is an ever-demanding and evolving concept, so equal distribution is an ideal rather than an achieved end in itself. The important thing about justice is fairness. How does one be fair to the other when there is an equal or greater demand for goods and services? It requires an attitude and belief in caring, a way of giving and often giving up for the other. In a family situation, a mother may have to attend to one child’s needs over the other in a particular situation. In nursing, on a unit when there is an equal demand for care and nurse caring and staffing ratios are minimal, often choices have to be made such that the more ill patient or the patient or family member in the greatest need will get the attention at a particular time. Resource allocation of goods, money, and services and interpersonal resources require sacrifice, thoughtfulness, communication, and advocacy for direct nurse-patient care, organizational management, and health and social policy development. Fidelity is an ethical principle that relates to faithfulness and keeping promises. In nursing, the principle of fidelity means loyalty to the patient within the nurse-patient relationship (Burkhardt & Nathaniel, 2008). Nurses make promises to their patients by means of the social contract of a nursing license or certificate of competence and as they care for the patients. Nurses must do everything in their power to be a patient advocate. With the rise of individualism in culture and perceived lack of mutual trust between nurse and health-care organizations, institutional loyalty has been seriously jeopardized (Ray, Turkel, & Marino, 2002; Turkel & Ray, 2004).

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Nursing Reflection What is a principle? Why do we have ethical principles in nursing, medicine, or health care? What are the personal and professional codes of ethics that motivate your ethical thinking and behavior? How have you developed principled behavior in your life and professional education or practice? Have you found a way to clarify your values and principles to be more cognizant of biomedical principles? What principles are priorities in nursing practice? How do you identify with the biomedical principles when you are in a nursing situation or educational facility? Are there times when ethical principles are jeopardized in educational settings or in nursing practice? Do patients trust nurses, physicians, or administrators? Do nurses trust patients, physicians, or administrators?

Ethics of Care/Caring In philosophy, the Ethics of Care emerged during the feminist movement within the latter part of the 20th century. Feminist ethics illuminated women’s basic moral orientation to that of caring for others—compassion and taking care of others in an interpersonal way (Chinn, 2013; MacKinnon & Fiala, 2014; Rachels, 2003). Gilligan (1982), one of the first women and leading scholars of her time, engaged in a critique to correct the misperceptions in psychology by illuminating the motives, the growth, and development of morality of women and women’s moral commitments. The ethical principles that emerge from most of these feminist theories of care show the dynamics of relationships and the concept of responsibility to the other—the good is equated with caring for others. “Care becomes the self-chosen principle of a judgment that remains psychological in its concern for relationships and response but becomes universal in its condemnation of exploitation and hurt” (Gilligan, 1982, p. 74). Even though the focus of modern feminine psychology and ethics is oriented to a new approach to feminine moral development, many ideas are based upon theological and human virtues of classical and medieval periods. What is new is the focus of attention on relationship, the call, and response of one person to the other, and care as central to moral development in women.

This orientation illustrates how important the meaning of care and caring was to the survival of human beings, as has been identified in anthropology (Leininger, 1978, 1991, 1995; Tarlow, 2000). The orientation to care and caring illuminates the relational idea of respect for self and other human beings. The character traits of caring capture the meaning of a truly good human being, one who cares and is responsible for others. At the same time, a caring human being is one who is conscious of the potential for selfishness in the individual self but lives in accordance with a moral code that enhances a sense of belonging to others, the world, and the universe at-large (Capra, Steindl-Rast with Matus, 1991).

The ethics of care and caring in nursing became prominent with the evolution of the concept of caring in nursing and also, at the same time, the ethics of care theme advanced in psychology. A guiding moral framework of ethical caring (enhancement and protection of human dignity, alleviation of suffering, and the nursing event/situation) in nursing was advanced by many theorists of caring (Davidson, Ray, & Turkel, 2011; Eriksson, 1997, 2006; Leininger, 1990; Ray, 1994a, 1994b, 1997, 1998, 2007, 2010a, 2010b, 2010c; Roach, 2002; Watson, 1988, 2005, 2008). Although complex and even paradoxical, evaluation and research have shown that in nursing situations, nurses integrate both the ethics of principle/duty and reason and the ethics of caring, healing, and responsibility (Cooper,

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1991; Hilsenbeck, 2006; Ray, 1987, 1998, 2007; Roach, 2002). Within this synthesis, there usually is creative moral tension that facilitates insight into and understanding of moral confusion and moral chaos, and the agonizing vulnerability in relation to the complexity of ethical decision making in the nursing situation (Chase, 2004; Gadow, 1989). Nursing continues to contribute to the understanding of caring as a moral enterprise—a value, virtue, intentional act, reason, and practical wisdom—a call and response and responsibility to self, others, the environment, and the universe.

Transcultural Ethics Transcultural ethics is very complex and dynamic. Each individual is a collage and integration of diverse values, beliefs, attitudes, and behaviors that make up human experience. Culture relates to patterns of learned behaviors and values that are interpreted and shared among members of a designated group and usually transmitted to others of their group through time (Leininger, 1978, 1990, 1991). Ethics is grounded in consciousness and conscience, which underscores beliefs about why we exist. Ethics is humanistic and principle-based and reveals a broader religious or spiritual purpose of reasons why we exist and how we should relate to and act with each other. Ethics is associated with respect for persons and moral action in the lifeworld and in living with others (American Nurses Association Code of Ethics with Interpretive Statements, 2001, 2015, www.nursingworld.org/codeofethics). The immediate purpose of transcultural ethics is to “hear the other” and “learn from the other” with mutual respect. This validates the idea that all people are cultural beings and have diverse values, beliefs, and attitudes. As cultural beings relate, transcultural ethics offers a framework within which to interact. The conscience in which this ethics illuminates strives to mitigate disrespect or elements of misconduct and to propagate the good, purpose, truth, and beauty within the interactions of all people and in nursing, nurses and patients, families or community groups.

Nursing Reflection What does an ethic of care and caring mean to you? How do you practice an ethic of care and caring with patients? What do healing and responsibility for the other mean to you? Is caring a universal principle and a culturally relative way of being? Do you find it hard to practice an ethic of care/caring in nursing today? What creative tension have you experienced between a set of principles, such as beneficence, autonomy, justice, and compassion or mercy? What principles and virtues do you find difficult? Are you ever morally confused about what to do in nursing situations? Have you experienced moral conflict, blurring, or moral blindness (Gadow, 1988, 1989; Ray, 1998; Turkel & Ray, 2009) when it comes to a difficult ethical situation in nursing or health care? Have you seen immoral behavior in nursing or medical practice, outright wrong actions? How have you dealt with observable or your own silent moral problems? Are there gray areas in nursing ethics either in the classroom or in nursing practice situations of potential cheating or deceiving the patient or the organization, truth telling, and promise keeping?

In today’s challenging global culture, transcultural ethics seeks to understand differences in people in interaction with others. Transcultural ethics validates the idea of increasing and learning compassion and reaching out to alleviate suffering—to help

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human beings by meeting needs and trying to secure human rights (individual or communal), and do what is just for others (Dalai Lama 1999; Hirsch, 1976; Leining