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Bioethical issues in nursing
- 1. Bioethical Issues in Nursing Presented By; Ms.Priyaniranjana J. PBD-Operation Room Nursing, CON,JIPMER.
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- 3. Introduction to Bioethics • Thestudy of the ethical and moral implications of new biological discoveries and biomedical advances, as in the fields of genetic engineering and drug research is bioethics. • The term “bioethics” was introduced in the 70’s by Van Rensselaer Potter for a study aiming at ensuring the preservation of the biosphere. • It was later used to refer a study of the ethical issues arising from health care, biological and medical sciences.
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- 5. Importance of Bioethics •Bioethics education for medical practice is essential in today’s complex world because; • Medical policies and patient rights legislation are ever-changing • Health care system function differently than before • Clinical practice now involves decision- making about many new issues.
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- 7. Definition of terms •Ethics: ethics is a set of principles of right conduct which is motivation based on ideas of right and wrong. It guides to moral behavior by making choices or judgments. • Ethics Vs Moral: Morals are an individual frame work for decision making that includes personal values. Ethics are a generalized conceptual frame work for decision making. • Nursing Ethics: it is a system of principles that govern the actions of the nurse in relation to patients, families, other health care providers, policymakers and society.
- 8. Definition of terms •Bioethical Issues: areas of health sciences that are the subject of published, peer- reviewed bioethical analysis. • Health ethics: health ethics or medical ethics are the rules or standards governing the conduct of a person or the members of a profession relating to the study or practice of medicine. • Professional ethics: professional ethics are the rules or standards governing the conduct of a person or the members of a profession.
- 9. Definition of Bioethics Bioethicsis a branch of applied ethics that studies the philosophical, social and legal issues arising in medicine and the life sciences. It is chiefly concerned with human life and well-being, though it sometimes also treats ethical questions relating to the non-human biological environment.
- 10. When does anissue in practice/ research be an ethical issue? • When there is conflict of moral values, beliefs and objectives – E.g. between the health care providers and the patients. • When there is conflict of commitments and responsibilities – E.g. saving patients’ lives Vs. using the available resources ‘rationally’ • When there is the concern that our patients rights/ values are not respected • When the issues in focus is related to justice in allocating the available resources • Finally, when we, as care providers feel that we are not sure what we should do
- 11. THE THREE QUESTIONS& the three categories • The three questions are: How to take an (and not the) ethically acceptable decision to the issue in focus? Why did we take this decision? (I.e. why we chose this ethical option and not another?) How to implement the decision we have taken?
- 12. The three questions& THE THREE CATEGORIES • The three categories are: Clinical ethics is the one which is concerned with the ethical issues related to clinical practice in health care settings Research ethics is concerned with the protection of humans participating in research Organizational ethics which is concerned more with fair allocation of health care resources
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- 16. Ethical issues • Abortion •Euthanasia • Suicide • Determination of death • Cloning • Human experimentation • Fetal tissue and Stem cell technology research • Reproductive sterilization • HIV and other infections • Quality of life • Death and dying • Homosexuality • Birth control • Organ donation and transplantation
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- 19. Reproductive situations • Voluntaryreproductive sterilization as a contraceptive method may be contrary to the moral, ethical or religious beliefs of a caregiver. Consent is required to perform reproductive sterilization. Some facilities require consent from the patient’s spouse.
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- 21. Abortion • Legalized abortionsallows for induced termination of pregnancy. • In 1973, the US Supreme Court ruled that any licensed physician can terminate pregnancy during the 1st trimester with the woman’s consent. • During the 2nd trimester, the court requires a state statute that regulates abortion on the basis of preservation and protection of maternal health. • During the 3rd trimester, legal abortion should consider meaningful life for the fetus outside the womb and endangerment to the mother’s life and health. • By selective abortion, one or more fertilized ova may be aborted so that others may mature properly in a multiple pregnancy, which is perhaps a result of fertility drugs. • Although, by law, physicians may perform abortions in health care facilities, many people, individually and collectively, oppose abortion, believing that it is a form of active euthanasia because it takes the life of an innocent victim without consent.
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- 23. Human experimentation • Proceduresstill in development stages are performed in clinical research-oriented facilities with the patient’s informed consent. Those willing to be pioneers in human experimentation have given or will give hope to many patients with poor prognoses. A caregiver should decide if he or she wants to participate in experimental procedures.
- 24. Fetal tissue andStem cell research
- 25. Fetal tissue andStem cell research • Experimentation with human tissues may be of moral concern to some individuals. • The acquisition of the tissues in the form of embryonic tissue and implantation may take place. Fetal tissues lacks in lymphocytes that can cause graft-versus-host response. • Advantages of fetal tissue include rapid proliferation of cells, quick reversal of the host’s condition and differentiation in response to cues of the host tissue. • Studies have shown promise in treatment of diabetes mellitus, Parkinson’s disease and certain blood disorders. • Tissues from spontaneous abortion and ectopic pregnancy has generally undergo pathologic degradation and is not suitable for this use
- 26. HIV and otherinfections
- 27. HIV and otherinfections • Underlying attitudes about homosexuality and IV drug abuse may subconsciously influence the care of such patients. • Should it? – Are these patients any different from patients with hemophilia and those who become infected through a contaminated blood transfusion? – Should the infant with HIV be treated any differently than an infant with a congenital anomaly? – Does the diagnosis make a difference to the health care provider and to the quality of care that the patient receives? • Knowing that HIV infection is transmitted by blood and body secretions, conscientious application of standard precautions for infection control should provide protection against occupational exposure to HIV, hepatitis, tuberculosis and other communicable or resistant infections.
- 28. HIV and otherinfection • Other ethical questions concern screening and the reporting of test results versus confidentiality. – Do the same considerations apply to team members as to patient? – What constitutes valid reasons for restricting or terminating employment on the basis of health status? • Confidentiality, privacy and informed consent are human rights that should be protected, but the right to health care should be protected also. • Certain organism like AORN and AST believe that providers have a right to know the HIV or other infectious status of patients but that caregivers do not have the right to discriminate against HIV- positive patients. This question has broader implications than just the issue of being seropositive for HIV and no state mandates by law that a health care providers can refuse to provide care for a patient with HIV infection.
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- 30. Quality of life •Physician often must make critical decisions before or during any interventions regarding the quality of patients’ lives after procedures. Palliative procedures may relieve pain. Therapeutic procedures may be disfiguring. Life-support systems may sustain vital functions. Life-sustaining therapy may prolong the dying process. • Many questions arise regarding care of terminally ill, severely debilitated or injured and comatose patients. – What will be the outcome in terms of mental or physical competence? – When should cardiopulmonary resuscitation be initiated or discontinued?
- 31. Quality of life •Physicians decide, but all team members are affected by the decisions. • Patients with advance directives have made many of these difficult decisions while in a lucid mental state. • This saves the family or legal guardians the anguish of making the decision during times of duress. • This helps provide some closure and a small sense of satisfaction that the loved one’s wishes were known and followed.
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- 33. Euthanasia • How iseuthanasia defined? Is mercy killing ethical, legal or justified? Does the patient, family or guardian, physicians or courts have the right to decide to abandon heroic measures to sustain life? The patient who is aware of the options and whose decision-making capacity is intact has the right of self-administration. • The idea of euthanasia seems to violate traditional principles of medicine to preserve life, but our modern technologies can prolong life without preserving quality. • Quality of life can be interpreted as life that has a meaningful value. Most human beings value having cognitive abilities, physical capabilities, or both and living free of undue pain and suffering. • This raises the ethical question of whether physicians should do what they technologies can do.
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- 35. Right–to-die • Courts havedetermined that patients have a constitutional right to privacy in choosing to die with dignity or a common law right to withhold consent and refuse treatment. A mentally competent adult older than the age of 18 years can execute a living will, advance directive, directing physicians and other health care providers not to use extraordinary measures to prolong life. • No law or court precedents deal specifically with issue of DNR orders in the peri-operative environment. Institutional policies should address this matter.
- 36. Right–to-die • In anemergency, if there is doubt about the validity of DNR order or a question concerning reconsideration of the order, the caregiver should participate in the resuscitation. If there is a question of patient changing his or her mind, a second chance may not be an option during emergency situation. • The issue of discontinuation of life-sustaining measures becomes more difficult in a comatose, mentally incompetent patient who has executed an advance directive. Family members, in consultation with physician, may request DNR orders. Caregivers are obligated to follow DNR order.
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- 38. Organ donation and transplantation •As a result of the uniform Anatomical Gift Act of 1968, many adult carry cards stating that at death they wish to donate their body organs or parts for transplantation, therapy, medical research or education. Most states include this information on a driver’s license. If this legal authority is not available, some states have a required request law. In the event of legally defined brain death, the caregivers are required by this law to ask the family if they wish to allow organ retrieval for transplantation. • The accepted definition of irreversible coma for potential donors includes unresponsiveness, no spontaneous movement of respiration, no reflexes and a flat ECG. • Caregivers learn to cope with feeling associated with the procurement of donor organs in a manner similar to dealing with the sudden death of any patient.
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- 40. Death and dying •Intellectually, we know that death is inevitable. Death can be a difficult burden for caregivers to bear because our education, experience and philosophy are dedicated to survival. • Regardless of religious or cultural beliefs, death is a mystery, a passage from the known to the unknown. • Coping strategies that can help team members may include the following; – Realize that everyone involved is part of a team effort. – Believe in greater power than the skills of the team. – Sharing feelings with others. Encourage each other to share feelings associated with the loss. Crying is acceptable behavior. – Deal with patient’s death by identifying personally with the loss. Empathy is a positive emotion. Working through the grieving process brings a sense of closure to the relationship. – Arrange a visit with the hospital chaplain or rabbi.
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- 42. Answering difficult questions Balancin g science and morality Health care decisions Ethical decision making •What issafe care? •What does it mean to be ill or well? •What is the proper balance between science/technology and the good of humans? •Where do we find balance when science will allow us to experiment with the basic origins of life? •Nurses must examine life and its origins, as well as its worth, usefulness, and importance •Nurses must determine their own values and seek to understand the values of others •Decisions are made with the patient, family, other nurses, and other health care providers •Nurses must develop a reasoned thought process and sound judgment in all situations that take place within the nurse-patient relationship
- 43. Values formation and moraldevelopment Examining value systems Learning right and wrong Under standing moral developmen t theory Moving towards moral maturity
- 44. Ethical theory • Asystem of principles by which a person can determine what ought and ought not to be done. • Rooted in the assumption that an action or practice is right if it leads to the greatest possible balance of good consequences, or to the fewest possible bad consequences • Strongest approach for bioethical decision making—which action will lead to the greatest ratio of benefit to harm for all persons involved? Utilitarianism • Rooted in the assumption that humans are rational and act out of principles that are consistent and objective, and compel them to do what is right • A decision is right only if it conforms to an overriding moral duty and wrong only if it violates that moral duty • All decisions are made in such a way that the decision could become universal law Deontology
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- 46. Ethical decision-making model Situation assessment procedure Identify and analyze available alternatives foraction Select one alternative Justify the selection Identify the ethical issues and problems
- 47. Bioethical dilemmas: life,death and dilemmas in between • Definition • Dilemmas that pose a choice between perplexing alternatives in the delivery of health care because of the lack of a clear sense of right or wrong • Nurses should consider the dilemmas that might arise in a given practice setting
- 48. Bioethical dilemmas: life,death and dilemmas in between Life • Bioethical abortion issue •When does life begin? •Nurses serving in women’s and children’s health settings must be prepared to face this morally laden issue • Reproduction issue: influenced by genetic screening, genetic engineering, and cloning Death • Quality of life and definition of death issues: With advances in health care, what is usual and what is heroic care has become unclear • Euthanasia and assisted suicide present new ethical questions • Nurses in every setting must be prepared to consider end-of-life questions Dilemmas • Right to health care •Health care system more selective in the amount and type of treatment offered as a result of managed care •Is each person entitled to the same health care package? •Does ability to pay affect specific level of entitlement? •How ethical is gatekeeping in the new managed care system? •Access to health care and respect for human dignity are at the core of nursing practice
- 49. Ethical challenges • Thechallenge of veracity Issues of alternative treatments and acknowledgment of uncertainty test truth-telling Which treatment among two or more is best for the patient? Which of the new drugs should be used? Should every patient be subjected to every possible form of diagnostic treatment? Should patient be made aware of questions and various options surrounding care? Is disclosure of uncertainty beneficial or detrimental? • The challenge of paternalism Provider tries to act on behalf of the patient and believes that his or her actions are justified because of a commitment to act in the best interest of the patient Interferes with a patient’s right to self-determination
- 50. Ethical challenges contd., •The challenge of autonomy Makes way for the crucial legal step of informed consent When are patients competent to make informed consent decisions? Can family members or surrogates make decisions by proxy? Questions about informed consent are raised for minors, confused older adults, mentally compromised, imprisoned, inebriated, unconscious, and those in emergency situations Nurses also must take responsibility for understanding and educating people about advance directives • The challenge of accountability Nurses have an obligation to uphold the highest standards of practice, to assume full and professional responsibility for every action, and to commit to maintaining quality in the skills and knowledge base of the profession Obligation to denounce a harmful action or potentially threatening situation may fall to a fellow member of the profession; to remain silent is to consent to the action of the threatening situation
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- 52. Robotic surgery: Bioethical aspects •The use of robotic surgery has been increasing common today, allowing the emergence of numerous bioethical issues in this area. The overall result of the citations obtained from the selected 17 articles, which ever used for the preparation of the article. It contains brief presentation on robotics, its inclusion in health and bioethical aspects, and the use of robots in surgery.
- 53. Bioethical issues inconducting Pediatric Dentistry clinical research • Pediatric clinical research on new drugs and biomaterials involves children in order to create valid and generalizable knowledge. Research on vulnerable population, such as children, is necessary but only admissible when researchers strictly follow methodological and ethical standards, together with the respective human rights; and very especially when the investigation can’t be conducted with other population or when the potential benefits are specifically for that age group. Clinical research in pediatric dentistry is not an exception. The aim of the present article was to provide the bioethical principles and recommendations including informed consent, research ethics committees, conflict of interest and the “EQUIPOISE concept”.
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- 56. Book reference • Potter,Perry. Fundamentals of Nursing. Elsevier publications. 7th ed. 2009. 1328-30. • Berry, Kohn. Operating Room Technique. 11th ed. Elsevier publications: 2007; 21, 369-84. • Ghaiath M. Bioethical issues in patient’s safety practice and research. Ehtics of pt. safety. 2008; 4: 5-40 • Sutradhar M. bioethics. J Plant Biotech. 2014: 55-78
- 57. Journal reference • Siqueira-BatistaR et al. Robotic surgery: Bioethical ascepts. Arq Bras Cir Dig. 2016; 21: 56-9 • Garrocho-Rangel A et al. Bioethical issues in conducting Pediatric Dentistry clinical research. J Clin Pediatr Dent. 2017; 10: 20-8