Ethico 2014

ETHICO – MORAL
ASPECT OF NURSING
Nelia B. Perez RN, MSN
PCU – MJCN
Class 2014
#mjcn

Learning outcomes
• Discuss the concepts of ethics and morality and their
application in the health care field
• Describe some ethical theories that may be used to
guide ethical decision-making
• identify factors that affect ethical decision-making
• Analyze ways in which sociocultural and occupational
factors affect ethical decision-making for nurses
• Outline a framework for ethical decision-making
• Discuss how ethics relates to commitments to the
patient, commitment to personal excellence, and
commitment to nursing as a profession
#mjcn

Values, Morals, & Ethics
• Values: are freely chosen, enduring beliefs or
attitudes about the worth of a
person, object, idea, or action (e.g.
freedom, family, honesty, hard work)
• Values frequently derive from a person‟s
cultural, ethnic, and religious background;
from societal traditions; and from the values
held by peer group and family
• Values form a basic for Behaviour “purposive
Behaviour”; The purposive behavior is based
on a person‟s decisions/choices, and these
decisions/choices are based on the person‟s
underlying values.
#mjcn

• Values are learned and are greatly
influenced by a person‟s sociocultural
environment (e.g. demonstrate
honesty, folk healer, observation and
experience)
• People need societal values to feel
accepted, and they need personal values
to produce a sense of individuality.
• Professional values often reflect and
expand on personal values
• Once a person becomes aware of his/her
values, they become an internal control for
behavior, thus, a person‟s real values are
manifested in consistent pattern of
behavior
#mjcn

• Watson (1981) outlined 4 important values
of nursing:
• Strong commitment to service
• Belief in the dignity and worth of each
person
• Commitment to education
• Autonomy
• nurses often need to behave in a value-
natural way (i.e. being nonjudgmental)
#mjcn

• Nurses need to understand their own values
related to moral matters and to use ethical
reasoning to determine and explain their moral
positions.
• Moral principles are also important, otherwise, they
may give emotional responses which often are not
helpful.
• Although nurses can not and should not ignore or
deny their own and the profession‟s values, they
need to be able to accept a client‟s values and
beliefs rather than assume their own are the “right
ones”
This acceptance and nonjudgmental approach
requires nurses to be aware of their own values
and how they influence behavior
#mjcn

• What values you hold about
life, health, illness, and death.
• How do your values influence the nursing
care you provide?
• We should explore our own values and
beliefs regarding such situations as the
following:
• An individual‟s right to make decisions for
self when conflicting with medical advice
• Abortion
• End-of –life issues
• Cloning
#mjcn

• The process of becoming more conscious
of and naming what one values or
considers worthy is known as “value
clarification”
• In value clarification:
we examine what we believe is
good, bad, beautiful, worthy, meaningful,
…..and explore the process of
determining our personal values.
Why?
#mjcn

Facts vs. Values:
• Factual Statement: scientists often perform
painful experiments on animals.
• Value Statement: it is morally acceptable
(morally required, morally wrong) for us to
perform painful experiments on animals.
#mjcn

• Factual Statement: We created and used
the atomic bomb.
• Value Statement: Creating and using the
atomic bomb was morally right (morally
wrong).
• Factual statement: someday we will have
the technology to clone human beings.
• Value statement: It is morally acceptable
(unacceptable) to clone human beings
#mjcn

• Factual Statement: scientists often perform
painful experiments on animals.
• Value Statement: it is morally acceptable
(morally required, morally wrong) for us to
perform painful experiments on animals.
#mjcn

The purposes of value clarifications
 This increase our self-awareness or
understanding of ourselves and assist us in
making choices.
 It facilitates decision-making, because we
have a better grasp of our own value
system.
 Consequently, this will be helpful when you
are faced with an ethical dilemma
• Ethical dilemma occurs when an individual
must choose between two unfavorable
alternatives “e.g. assisted suicide”
#mjcn

• Ethical dilemma usually have no perfect
solution and those making decisions may
find themselves in the position of having
to defend their decisions
• Value conflict occurs when we must
choose between two things, both of which
are important to us.
• It‟s the nurses‟ role to help clients identify
values and clarify them……
But How??????
#mjcn

Helping clients identifying their
values
• List alternatives
• Examine possible consequences of choices
• Choose freely
• Feel good about the choice
• Affirm the choice
• Act on the choice
• Act with a pattern
Remember: never impose your personal values
never offer an opinion
#mjcn

Morals and Ethics
• Morals: is similar to ethics and many
people use the two wards interchangeably
(closely associated with the concept of
ethics)
• Derived from the Latin “mores”, means
custom or habit.
• Morality: usually refers to an individual‟s
personal standards of what is right and
wrong in conduct, character, and attitude.
• Morals: are based on religious beliefs and
social influence and group norms
#mjcn

Morals and Ethics (continue)
• Ethics is a branch of philosophy (the
study of beliefs and assumptions)
referred to as moral philosophy.
• Derived from the Greek word “ethos”
which means customs, habitual
usage, conduct and character.
• Ethics: usually refers to the
practices, beliefs, and standards of
behavior of a particular group such as
nurses. It also refers to the method of
inquiry that assists people to understood
the morality of human behavior (study of
morality)
#mjcn

Morals and Ethics (continue)
• In both, we describe the behavior we
observe as
good, right, desirable, honorable, fitting or
proper or we might describe the behavior
as bad, wrong, improper, irresponsible, or
evil.
[Such perceptions are based on values]
• There are times when a differences in
values and decisions can be accepted
• Differences in values and decisions put
people into direct conflict.
What to do in such situation?
#mjcn

Morals and Ethics (resolving conflicts)
• Be constructive (rather than destructive) in
the methods you choose to work toward
resolving the differences
• Listen carefully without interruptions
• Seek clarification using gentle questioning
• Respect cultural differences
• Be attentive to body language
• Explain the context of your point of view
and try to picture the other person‟s
expective of what you are saying
#mjcn

Comparison of morals and ethics
Morals
• Principles and rules of right
conduct
• Private, and personal
• Commitment to principles
and values is usually
defended in daily life
• Pertain to an individual„s
character
Ethics
• Formal responding process used
to determine right conduct
• Professionally and publicly
stated
• Inquiry or study of principles and
values
• Process of questioning, and
perhaps changing, one‟s morals
• Speaks to relationships between
human beings
#mjcn

Moral development
• Moral development is a complex process
that is not fully understood
• It is the process of learning what ought to
be done and what ought not to be done
• Different approaches to moral
development exists:
• Kohlberg‟s theory
• Gilligan
#mjcn

Moral distress
• When the nurses are unable to follow their
moral beliefs because of institutional or
other restriction.
• The distress occurs when the nurse
violates a personal moral value and fails to
fulfill perceived responsibility.
• Moral distress represent practical, rather
than ethical dilemmas.
#mjcn

Moral outrage
- Occurs when someone else in the health
care setting performs an act the nurse
believes to be immoral.
- Nurses do not participate in the act.
- Nurses not responsible for wrong but
perceive that they are powerless to
prevent.
#mjcn

Kohlberg Approach
• Directly affected by Piaget‟s theory of cognitive
development
• Focuses on the structure of though about moral
issues rather than the specific content of moral
values.
• Emphasizes fairness, rights and autonomy in a
justice framework
• Moral development progresses through three levels:
• Level I: premoral or preconventional level
• Level II: conventional level
• Level III: post conventional, autonomous or
principled level
#mjcn

Gilligan‟s theory
• Focuses on a care perspectives
• Organized around the notions of
responsibility, compassion (care),
relationships
• The ethics of justice (fairness) is based of
the idea of equality “everyone should
receive the same treatment”. By contrast,
the ethics of care is based on a premise
of nonviolence: that no one should be
harmed or abandoned
#mjcn

Gilligan‟s theory (continue)
• Process of developing an “ethics of care”
• Stage I: caring for oneself
• Stage II: caring for others
• Stage III: caring for oneself and others
• Each stage ends with a transitional period (a
time when the individual recognizes a
conflict or discomfort with some present
behavior and considers new approaches)
#mjcn

Moral/ethical principles (concepts)
• Are statements about broad, general
philosophic concepts such as
autonomy and justice
• They provide the foundation for moral
values, which are specific
prescriptions for actions (e.g. “people
should not lie” (rule) is based on the
moral principle of respect of autonomy
for people.
#mjcn

Basic ethical concepts
1. Rights
2. Autonomy
3. Beneficence and Nonmaleficence
4. Justice
5. Fidelity
6. Veracity
7. The standard of best interest
#mjcn

Rights
• Rights form the basis of most professional
codes and legal judgments
• Self-determination rights
• Rights and cultural relativism
• Rights of the unborn
• Rights of privacy and confidentiality
#mjcn

Autonomy
• Involves the right of self-
determination, independence, and
freedom.
• It refers to the right to make one‟s own
decisions
• Respect for autonomy means that nurses
recognize the individual‟s
uniqueness, the right to be what that
person is, and the right to choose
personal goals
• Nurses who follow the principle of
autonomy respect a client's right to make
decisions even when those choices
seem not to be in the client‟s best interest
#mjcn

Autonomy….. (continue)
• Respect for people also means treating
others with consideration
• In the clinical setting, this principle is
violated when a nurse disregards client's
subjective accounts of their symptoms
(e.g. pain)
• Patients should give informed consent
before tests and procedures are carried
out
#mjcn

Beneficence and Nonmaleficence
Beneficence: means “doing good”
• Nurses should implement actions that benefit
clients and their support persons. However, in an
increasing technologic health care system, doing
good can also pose a risk of doing harm (e.g.
intensive exercise program).
Nonmaleficence: means the duty to do no harm.
• This is the basic of most codes of nursing ethics.
• Harm can mean deliberate harm, risk of harm, and
unintentional harm.
• In nursing, intentional harm is always
unacceptable.
• The risk of harm is not always clear
• A client may be at risk of harm during a nursing
intervention that is intended to be helpful (e.g.
medication)
#mjcn

Justice
• Is often referred to as fairness
• Nurses frequently face decisions in
which a sense of justice should prevail
(succeed)
• E.g. busy unit, new admission
#mjcn

Fidelity
• Means to be faithful to agreements and
responsibilities one has undertaken
• Nurses have responsibilities to
clients, employers, government, society, the
profession, and themselves
• Circumstances often affect which
responsibilities take precedence at a
particular time
#mjcn

Verasity
• Refers to telling the truth
• As a nurse should I tell the truth when it
is known that doing so will cause harm?
• Does tell a lie when it is known that the
lie will relieve anxiety and fear?
• Should I lie to dying people?
#mjcn

The standard of best interest
• Applied when a decision must be made
about a patient‟s health care and the
patient is unable to make an informed
decision
#mjcn

Ethical theory
• An ethical theory provides a
framework within which agents can
reflect on the acceptability of
actions and can evaluate moral
judgments and moral character
#mjcn

Ethical theories
1- Teleology
2- Deontology
3- Institutionism
4- Ethic of caring
#mjcn

Ethical theories….(continue)
Teleology: looks to the consequences of an
action in judging whether that action is right or
wrong
Deontology: proposes that the mortality of a
decision is not determined by its
consequences. It emphasizes duty, rationality,
and obedience to rules
The difference between Teleology and
Deontology can be seen when each approach
is applied to the issue of abortion
#mjcn

Ethical theories…..(continue)
Example:
Teleology approach/abortion: saving the
mother‟s life (the end, or consequence)
justifies the abortion (the mean, or act)
Deontology approach/abortion: consider
any termination of life as a violation of
the rule “do not kill” and therefore, would
not abort the fetus, regardless of the
consequences to the mother
#mjcn

Institutionism: summarized as the notion that
people inherently know what is right or
wrong; determining what is right is not a
matter or rational thought or learning (e.g.
the nurse inherently knows it is wrong to
strike a client, the nurse does not need to
be taught this or to reason it out)
The preceding three theories are based on the
concept of fairness (justice)
#mjcn

Ethic of caring: it is based on relationships.
Caring is a force for protecting and
enhancing client dignity
Caring is of central importance in the client-
nurse relationship (e.g. nurses use trust-
telling to affirm clients as a persons rather
than objects and to assist them to make
choices and find meaning in their illness
experiences)
#mjcn

Guidelines for Ethical Reasoning
 Stay open-minded. Challenge your own views. It‟s
not enough just to hold a position, you must be able
to support it with good reasons.
 Challenge the views of others if you disagree with
them, but do so respectfully and considerately.
 Philosophical discussion loses most of its value if
it‟s used as a place to dominate or show off.
 Philosophical discussion is best done as a
community enterprise, where all the discussants
work together to get closer to the truth.
#mjcn

Nursing Codes of Ethics
• A code of ethics is a formal statement of a
group‟s ideals and values.
• It is a set of ethical principles that is shared by
members of the group, reflects their moral
judgments over time and serves as a standard
for their professional actions.
• Codes of Ethics are usually higher than legal
standards
• International, national, state nursing associations
have established codes of ethics
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Nursing Codes of Ethics (purposes)
1. To inform the public about the minimum standards of
the profession and to help them understand
professional nursing conducts
2. To provide a sign of the profession‟s commitment to
the public it serves
3. To outline the major ethical considerations of the
profession
4. To provide general guidelines for professional behavior
5. To guide the profession in self-regulation
6. To remind nurses of the special responsibility they
assume when caring for clients.
#mjcn

Nursing Codes of Ethics (elements)
• Nurses have four fundamental
responsibilities: to promote health, to prevent
illness, to restore health, and alleviate
suffering.
• Nurses and people
• Nurses and practice
• Nurses and the profession
• Nurses and the co-workers
#mjcn

What is Ethical Decision Making?
• When faced with an ethical dilemma the
objective is to make a judgment based on
well-reasoned, defensible ethical
principles.
• The risk is poor judgment i.e. a low-quality
decision
• A low-quality decision can have a wide
range of negative consequences
#mjcn

Two Types of Ethical Choices
• Right vs wrong: choosing right from wrong
is the easiest
• Right vs right
• Situation contains shades of gray i.e. all
alternative have desirable and
undesirable results
• Choosing “the lesser of two evils”
• Objective: make a defensible decision
#mjcn

Factors that influence EDM
1. Codes for Nurses
2. The patient‟s rights
3. Social and cultural attitudes
4. Science and technology
5. Legislation
6. Judicial decisions
7. Funding
8. Personal religious and philosophic viewpoint
#mjcn

Factors in the work environment that
affect EDM
1. Status as an employment
2. Collective bargaining contracts
3. Collegial relationships
4. Authoritarian and paternalistic
background
5. Ethics committees in health care
6. Consumer involvement in health care
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A framework for Ethical Decision
Making (EDM)
1. Identify and clarify the ethical problem
2. Gather data
3. Identify options
4. Make a decision
5. Act and assess
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Making Moral Decisions--Some
Inappropriate Ways:
• Appeal to Authority
• Appeal to Law
• Appeal exclusively to self-interest
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Some Guidelines for Making
Ethical Decisions
1. Choose correct moral language.(Often, the
way in which you initially
conceptualize a situation will affect
what moral conclusions you will make)
2. Be as clear as you can about the
facts, both empirical and philosophical
3. Consider the relevant moral principles and
rules, and make your best judgment.
#mjcn

Ethics Committees
With the increasing complexity of ethical issues in
health care, ethics committees have been created
to assist in making ethical decisions in clinical
settings. Ethical committees can:
1. Provide structure and guidelines for potential
problems.
2. Serve as an open forum for discussion and debate.
3. Function as a patient advocate by placing the
patient at the core of the committee‟s deliberations.
#mjcn

Case Studies
• Mrs. C., an 85-year-old woman with
severe emphysema, is found
unresponsive by her husband. He calls
for an ambulance. Emergency medical
personnel perform endotracheal
intubation and resuscitate her
successfully. She then is taken to the
local hospital for treatment of
pneumonia and respiratory failure.
After treatment for her medical
conditions, she cannot be weaned from
the respirator.
#mjcn

• The patient is able to communicate her
wishes by using head signals and
writing notes. After several weeks of
treatment, she asks that the respirator
be discontinued and she be allowed to
die. Mrs. C. asserts emphatically that
she would not have wanted to be
resuscitated in the first place, although
she never executed an advanced
directive or discussed these specific
wishes with anyone.
#mjcn

Discussion Questions
• Is the patient‟s decision a rational one?
• What is the difference between withholding
and withdrawing life-sustaining treatment?
• In view of the fact that a potent sedative
such as morphine may produce respiratory
depression, should this be given prior to
discontinuing the respirator? Would this
constitute active euthanasia?
• Would the situation be different if Mrs. C.
had a living will?
• What role could the nurse play in
addressing the ethical issues in this case?
#mjcn

notes
• Euthanasia
Greek words meaning “easy death”.
Euthanasia is an act by which the causative agent
of death is administered by another with the
intent to end life.
Killing an innocent person, even at his or her
request is not ethical.
“Code for Nurses (1985) and the ANA position
statement (1994) states that the nurse should
not participate in euthanasia but be vigilant
advocates for the delivery of dignified and
human care.
#mjcn

• Living Wills
Prepared while patient has decisional capacity
Describes patient preferences in the event they
become incapable of making decisions or
communicating decisions.
Usually describes what type of life prolonging
procedures the patient would or would not
want and circumstances under which they
would want these procedures carried
out, withheld, or withdrawn
#mjcn

Ethico 2014

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