DEFINITIONS
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Ethics2019Notes1--41.pptx
Ethics in Nursing
NUR 4242
Notes # 1
Social, Philosophical, and Other Historical Forces Influencing the Development of Nursing
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Introduction
Moral action is the historical basis for the creation, evolution, and practice of nursing.
Moral beliefs produce rules of action, or ethics.
Throughout history, spiritual beliefs, religious practice, philosophy, cultural norms, and political factors influenced changes in nursing.
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Introduction
In the United States, Western tradition and philosophy is the predominate context for nursing.
In an increasingly multicultural environment, it is important to fully appreciate the beliefs and traditions of others.
Social Theory
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We can only understand each aspect of a social phenomenon in relation to the history and structure in which it is found.
To understand the meaning of ideas and behaviors, we must objectively view them in the context of historical and social practices and entanglements of power and interest.
Influence of Social Need
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Social need is the criterion for the existence of all professions.
Helping professions find their origin, purpose, and meaning within the context of culturally accepted moral norms, individual values, and perceived social need.
ANA Social Policy Statement
Moral Thought
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Related to the thoughtful examination of right and wrong, good and bad.
Begins as individuals’ or groups’ desire to meet the needs of others.
Empathy is a motive for moral reasoning and action.
Moral Thought and Nursing
The practice of nursing is focused on meeting the health care needs of others; therefore, the practice of nursing originates in moral thinking.
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Nursing as Part of Society
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Professions exist to meet the needs of society.
Nursing must serve the interest of the “larger whole of which it is a part.”
Society grants professionals the exclusive right to practice within defined limits.
Professionals have a reciprocal duty to society to practice competently.
Spiritual/Religious Influences
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Contribute to the moral foundation of nursing
Influence the gender and activities of healers
Influence beliefs about the value of individuals, life, death, and health
Spiritual/Religious and Nursing
Nursing in some form has existed in every culture and been influenced by spiritual beliefs, religious practices, and related cultural values.
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Gender Influences
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In every culture, women have been healers.
Women’s status in society is central to determining the extent of freedom and respect granted to nurses.
Philosophical Influences
Philosophers ask important questions and propose theories that shape culture and influence society.
Questions about truth and reality
Theories about morality and the good life
Theories that impact the scientific method
Ancient Times
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Cosmology describes how people of the culture view the structure, origin, and processes of the universe.
Early culture linked healers with the sacred.
There is early and diverse cultural evidence of women as healers and priestesses.
Ancient Times
Women were leaders in the healing arts when the reigning deity was feminine, bisexual, or androgenous.
As deities became more masculine the woman’s role as an independent, primary healer was taken away.
Ancient Greeks
Asclepius was the mythical god of medicine and healing. His followers established temples of healing or asclepieions.
Some of his mythological children included:
Hygieia—goddess of health—“hygiene”
Panaceia—goddess of healing—“panacea”
Iaso—goddess of medicine
Ancient Romans
Also worshipped Asclepius. Hippocrates may have studied at an asclepion.
Hippocratic oath begins, “I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea…”
The “Staff of Asclepius” is a snake ascending a staff. It is the official symbol of the AMA and AOA.
Mosaic Health Code
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Was applied to every aspect of individual, family, and community life, including rest, sleep, cleanliness, hygiene, hand washing, care of food, and childbearing
Required inspection of food, detection and reporting of disease, methods of disposal of excreta, feminine hygiene, and isolation of those with communicable illness
Hippocrates: Father of Western Medicine
Revolutionized healing arts in Greece, established medicine as a profession, believed the care of the sick included observation, symptoms, rational conclusions, and a predictable prognosis.
Proposed the role of healing was to reinstate the healthy balance of four bodily humors.
The Hippocratic oath is attributed to him.
Philosophy in Ancient Times
Philosophers began questioning beliefs, mythologies, and folklore.
Used abstract thinking and asked questions about nature, religion, the origins and nature of things, and the nature of reality and truth
Socrates, Plato, and Aristotle proposed new ideas about truth, reality, relationships, ethics, and the right way to live.
Philosophy in Ancient Times
Socrates developed the Socratic method of teaching, which provides a systemic and objective approach to problem solving.
Aristotle proposed that the aim of the good life is eudaimonia (happiness, flourishing), which is achieved through a virtuous life of excellence.
Early Christian Era
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Exerted profound influences on healing beliefs and practices.
With religious belief in a single male god, women’s healing role changed from that of a sacred healer to subservient caregiver.
Women’s place in the healing art was minimal when Jesus lived, but he challenged traditions by associating freely with women.
New Testament
The New Testament message regarding the care for others:
Caring for others represents caring for Jesus.
A spiritual reward is gained by caring for others.
Even in an evil world, one should love God and one’s neighbor.
Every person is an important member of God’s Kingdom.
Every person has worth and dignity.
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Philosophy: Early Christian Era
St. Paul was a highly influential philosopher who held that there is a natural law of conscience in each person.
St. Augustine believed true reality was spiritual and Being comes from God. He emphasized the inner life and contemplation of God and examined the passions of the soul.
Philosophy: Middle Ages
Middle/Dark Ages saw social disruption and cultural deterioration. Most philosophy was theological at this time.
Thomas Aquinas synthesized Greek rationalism and Christian doctrine, which became the cornerstone of Catholic philosophy.
Retranslation of Plato and Aristotle (later Middle Ages).
Nursing in the Middle Ages
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Based on imitating Jesus, who spent his life ministering to those in need.
Service was viewed as a means of securing salvation.
Religious orders were the way respectable women and men could serve as nurses.
Influences of Middle Ages Church
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Credentialed health professionals.
Deeply anti-empirical beliefs.
Believed only God and the devil had the power to cause illness or promote healing.
Religious fervor saw treatment not approved by the Church as the work of the devil.
Women healers persecuted.
Health and the Crusades
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Deplorable sanitary conditions, fatigue, poor nutrition, diarrhea, and the spread of communicable diseases
Military nursing orders formed as a response, which drew a large number of men into the field of nursing
Treatment
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Some patients were treated as welcome guests; others were treated inhumanely.
Nurses who believed their duty was to God/the spiritual may have paid less attention to physical, emotional, and comfort needs.
Mental illness was seen as possession by the devil or punishment for sins.
Patients chained, starved, and sometimes tortured to try to drive out madness.
Women in the Middle Ages
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“Women was created to be man’s [helper] but her unique role is conception…since for all other purposes men would be better assisted by other men.” Thomas Aquinas
“Woman is the gate of the devil, the path of wickedness, the sting of the serpent, in a world a perilous object.” St. Jerome
Women healers represented a political, religious, and sexual threat to both Church and state, which added to the beginning of the witch hunts.
Women in the Middle Ages
Religious- and Church-sanctioned secular nursing orders were the only avenues for women as nurses.
During the Crusades, nursing orders provided care in infirmaries and clinics.
Nursing orders were subordinate in the Church, but these women did exercise a degree of autonomy and independence.
Reformation
Led to laws and customs that discouraged the humane care of the poor and vulnerable
“Dark period of nursing”
Nursing orders expelled from hospitals
Hospital care provided by convalescent patients, prostitutes, prisoners, and drunkards
Also allowed for new types of thinking and opened the door for the Renaissance
Renaissance
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Birth of scientific revolution and a new era in the healing arts.
Philosophical humanism emerged with humans rather than God as the focus.
Empiric phenomena and subjective reasoning became the focus of knowledge.
Brought relief from witch hunts but didn’t really change the lives of women.
Modern Era
Brought tremendous advances in science, politics, and philosophy.
Modern philosophers’ ideas directly influenced nursing.
Cartesian philosophy resulted in a separation between the acts of caring and curing.
Nurse’s role restricted to the caring realm.
Florence Nightingale
Florence Nightingale worked to free nursing from the bonds of the church.
Became a model for all nurses.
Addressed moral and social issues.
Was a nurse, statistician, sanitarian, social reformer, and a scholar.
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Think About It and Discuss
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Nursing is primarily a profession of women. How has the social status of women affected the status of the profession in the past and present?
Does the status of the nursing profession change its members’ ability to practice? Explain your answer.
Ethical Theory
Notes # 2
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Ethics and Nursing
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It is through the intimacy and trust of the nurse-patient relationship that nurses become critical participants in the process of ethical decision making.
By developing a working knowledge of ethical theory, nurses can make clear and consistent decisions.
Philosophy
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The intense and critical examination of beliefs and assumptions.
It gives coherence to the whole realm of thought and experience and offers principles for deciding what actions and qualities are most worthwhile.
It gives shape to what would otherwise be a chaos of thoughts, beliefs, assumptions, values, contradictions, and superstitions.
Moral Theory
Provides a framework for cohesive and consistent ethical reasoning and decision making.
The best moral theories are part of larger integrated philosophies.
Two moral theories having the greatest influence on contemporary bioethics and nursing: utilitarianism and deontology.
Morals and Ethics
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Moral philosophy is the philosophical discussion of what is considered good or bad, right or wrong, in terms of moral issues.
Moral issues are those which are essential, basic, or important and deal with important moral issues.
Ethics is a formal process making logical and consistent decisions, based upon moral philosophy.
Ethical Theories
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Ethical theories explain values and behavior related to cultural and moral norms.
As a morally central health care profession, nursing requires astuteness concerning moral and ethical issues.
Professional codes of ethics provide a formal process for applying moral philosophy and ethics.
Naturalism
Regards ethics as dependent upon nature and psychology.
Proposes that nearly all people have a tendency to make similar ethical decisions despite differences in culture.
Sympathy is a motivating factor in moral decision making.
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Rationalism
Rationalists believe feelings or perceptions, though they may seem similar in many people, may not actually be similar in all people.
Believe there exist universal truths, independent from humans, that can be known through the process of reasoning.
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Utilitarianism
Sometimes called consequentialism, holds that an action is judged as good or bad in relation to the consequence, outcome, or end result that is derived from it.
Holds that no action is in itself either good or bad.
Mill believed it to be in the spirit of the golden rule, “Do unto others as you would have them do unto you.”
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Types of Utilitarianism
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Act-utilitarianism: people choose actions that will, in a given circumstance, increase the overall good.
Allows for different, sometimes opposing, action in different situations.
Rule-utilitarianism: people choose rules in all situations that increase the overall good.
Rules that maximize happiness and reduce unhappiness.
Rules are easy to learn and should be strictly followed.
Deontology
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Deontology is based upon the idea that rightness or wrongness of an act depends upon the nature of the act, rather than its consequences.
Ethical rules are universal, and humans can derive certain consistent principles to guide action.
Moral rules are absolute and apply to all people.
Kantianism
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Kantianism is a particular deontological theory developed by Immanuel Kant.
The categorical imperative assumes that if an action is morally right, it is reasonable to imagine it as a strict universal law.
The practical imperative requires that one treat others always as an end and never as a means only.
Virtue Ethics
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No rules or principles. Rather, actions are based upon a degree of innate moral virtue.
A moral virtue is a character trait that is morally valued.
A virtuous person has consistent moral action and morally appropriate desire and will naturally choose the morally correct action.
Focal Virtues
Although people have different character traits, all have the capacity to learn or cultivate those that are important to morality.
Compassion
Discernment
Trustworthiness
Integrity
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Compassion
The ability to imagine oneself in the situation of another
An attitude of active regard for another’s welfare with an imaginative awareness and emotional response of deep sympathy
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Discernment
A sensitive insight involving acute judgment and understanding, and eventuating in decisive action
Allows us to see appropriate actions in a given situation and requires sensitivity and attention attuned to the demands of a particular context
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Trustworthiness
A confident belief in and reliance upon the ability and moral character of another person
Entails a confidence that another will act with the right motives in accord with moral norms
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Integrity
Moral integrity means soundness, reliability, wholeness, and an integration of moral character.
Refers to our continuing to follow moral norms over time.
One with integrity has the consistency of convictions, actions, and emotions and is trustworthy.
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Moral Particularism
Embraces the uniqueness of particular cases including the context, culture, situations, relationships, and individuals involved
Recognizes the need for rules that allow for exceptions in situations that deviate from the norm
Relies on other relevant moral principles for the starting point of judgment
Notes # 3
Ethical Principles
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Ethical Principles
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Basic and obvious moral truths that guide deliberation and action
Presuppose a basic respect for persons
Included in moral theories, although sometimes in different ways
Respect for Autonomy
Definition: self-governing
Freedom to make decisions about issues that affect one’s life free from lies, restraint, or coercion.
The autonomous person
Is respected
Is able to determine personal goals
Has the capacity to decide upon a plan of action
Is free to act on choices
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Autonomy
Value of autonomy is culturally dependent.
Some cultures don’t regard all people as of equal value.
Some cultures value social structure over individual rights.
Respect for autonomy does not require respect for all autonomous decisions.
Must uphold respect for self and others who might be harmed by another’s choices.
Respect the principle rather than each action or choice.
Informed Consent
Practical application of the principles of respect for autonomy.
Demonstrates legal protection of personal autonomy in regard to specific medical treatments and procedures
Contemporary informed consent is a direct outcome of past research atrocities.
Paternalism and Advocacy
Paternalism: places power in the hands of the person who is making the decision for the patient. Implies that the decision maker knows what is best.
Advocacy: ensures the patient’s welfare and respects the patient’s autonomy because it aims to act according to the patient’s values.
May unwittingly cross from advocacy to paternalism
Noncompliance
Lack of participation in a regimen that has been planned by the health care professional but must be carried out by the patient.
Patient must have autonomous participation in plan formation
Nurse must assess the patient’s ability to carry out the plan
Ultimately, choices about health care practices belong to the patient.
Beneficence
Requires one to act in a way that benefits others:
Do or promote good
Prevent harm
Remove evil or harm
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Do or Promote Good
Ask yourself:
How does one decide what is good?
When people disagree, who gets to decide?
Should other ethical principles, such as truthfulness and autonomy, be violated in the process of doing good?
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Prevent Harm
Ask yourself:
In what instances might a nurse be compelled to prevent harm?
How far should a nurse go to prevent harm?
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Remove Evil or Harm
Ask yourself:
In what type of situations would a nurse need to remove harm?
What are the risks to the nurse?
What characteristics does a nurse need in order to remove harm in a difficult situation?
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Nonmaleficence
Requires one to refrain from causing harm, including:
Deliberate harm
Risk of harm
Harm that occurs during the performance of beneficial acts
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Think About It
Doing good often includes causing harm; for instance, a surgeon might save a life (doing good) by amputating a limb (causing harm).
How does one balance good and harm?
When the outcome is unsure, who decides?
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Veracity
Definition: telling the truth
Implies respect for others.
Is required of those who support autonomy of others.
Authorities disagree on the absolute necessity of truth telling in all instances.
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Confidentiality
Definition: nondisclosure of private or secret information about another person
A traditional tenet of nursing and medical ethics
A legal mandate in nearly all cases
Is sometimes limited by harm and vulnerability
Flows from respect for persons and their autonomy
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Justice
Relates to fair, equitable, and appropriate treatment in light of what is due or owed to persons
Recognizes that giving to some will deny receipt to others who might otherwise have received these things
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Distributive Justice
Application of the principle of justice that focuses on distribution of goods and services
To each equally
To each according to need
To each according to merit
To each according to social contribution
To each according to the person’s rights
To each according to individual effort
To each as you would be done by
To each according to the greatest good to the greatest number
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Material Rules of Distributive Justice
Systematic means of deciding such as:
Give to each person equally
Give to those who need it most
Give to those who deserve it most
Give to those who can pay for it
Give to those who arrive first
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Use of Material Rules
Which material rule is used when:
Private hospitals turn away indigent patients?
Immunizations are given to all fifth graders?
A free clinic accepts only the first 30 patients?
Scholarships go to those with low incomes?
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Fidelity
Definition: faithfulness and promise keeping
Nurses must faithfully
Uphold the profession’s code of ethics
Practice within established scope of practice
Practice competently
Keep promises to patients
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Chapter 4
Values Clarification
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Values
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Values are ideals, beliefs, customs, modes of conduct, qualities, or goals that are highly prized or preferred by individuals, groups, or society.
Values influence choices and behavior, whether or not we are consciously aware of this influence.
Expressed by choices and behavior in daily life
Moral Values
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Individual cognitive evaluation of right and wrong, good and bad, is reflective of moral thought.
Preferences or dispositions reflective of right or wrong, should or should not, in human behavior are considered moral values.
Acquiring Values
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Personal ethical behavior flows from values held by an individual that develop over time.
Cultural, ethnic, familial, environmental, educational, and other experiences of living help shape our values.
Self-Awareness
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Ethical relationships with others begin with self-knowledge and the willingness to express that awareness to others honestly and appropriately.
Self-knowledge is an ongoing, evolving process that requires us to make a commitment to know the truth about ourselves.
Values Clarification
Refers to the process of becoming more conscious of and naming what we value or consider worthy.
May lead to different insights for different people
Be willing to take an honest look at personal ideals, behavior, and motives
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Enhancing Self-Awareness
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Goes hand in hand with values clarification
The first and most important step in awareness of the self is the conscious intention to be aware of one’s:
Thoughts
Feelings
Emotional and physical responses
Insights into various situations
Motives
Valuing Process
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Prizing and cherishing one’s beliefs and behaviors
Choosing one’s beliefs and behaviors by evaluating values received from others
Acting on these beliefs with a consistent pattern that reinforces actions supportive of these values
Journaling
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Keeping a written record
Important to assist one in becoming aware of his or her own values
Values in Professional Situations
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It’s important for the nurse to identify his or her own values, thoughts, and motives.
Values conflict.
When personal values are in conflict or at odds with a patient’s, colleague’s, or institution’s values.
Overt Values
Values of individual institutions and organized health care systems that are explicitly communicated through philosophy and policy statements
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Covert Values
Values that may be implicit in expectations that are not in writing.
Many times, these covert values are only identified through participation in or controversies within the setting.
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Moral Distress
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Reaction to a situation in which there are moral problems that seem to have clear solutions, yet we are unable to follow our moral beliefs because of external restraints.
This often leads to a miserable work life.
Clarifying Values with Patients
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Patients are consumers of health care.
Nurse and health care workers are providers of health care.
Patient and provider perceptions of what constitutes quality of care can be quite different.
