2. Objectives
• Define values, beliefs, attitudes, ethics and
morality.
• Understand the moral frameworks
• Explain how values, moral frameworks and
codes of ethics affect moral decisions.
• Explore everyday ethical issues in nursing
3. Values
• Values are enduring beliefs or attitudes about the
worth of a person, object, idea or action.
• Nurses recognise the client as an individual and
take into consideration his or her beliefs and
values.
• Values influence decisions and actions, including
nurses’ ethical decisions.
• People have may different beliefs and attitudes,
but only a small number of values.
(McPherson & Stakenberg, 2012)
4. Beliefs and attitudes
• Beliefs are interpretations or conclusions that
people often accept as true
• Attitudes are mental positions or feelings
towards a person, object or idea, such as
acceptance, compassion, openness.
(McPherson & Stakenberg, 2012)
5. Ethics
• A method of inquiry that helps people to
understand the morality of human behaviour
• The practices or beliefs of a certain group
• The excepted standards of moral behaviour of
a particular group as described in the group’s
formal code of professional ethics.
6. Morality
• Morality refers to private, personal standards
of what is right and wrong in conduct,
character and attitude.
• Person-centred care is characterised by an
appropriate level of communication and
response to the client; it is inappropriate for
nurses to impose their moral standard on the
client.
7. Moral Frameworks
• Consequence-based (teleological) theories – to
look at the outcomes of an action in judging
whether that action is right or wrong. E.g.,
Utilitarianism
• Principles-based (deontological) theories – to
emphasise individual rights, duties, and
obligations.
• Relationship-based (caring) theories – to stress
courage, generosity, commitment and the need
to nurture and maintain relationship.
8. Moral principles
• Moral principles are statements about broad,
general, philosophical concepts such as
autonomy and justice. They provide the
foundation for moral rules, which are specific
prescriptions for actions.
9. Moral principles - Autonomy
• Autonomy is about the freedom to choose a
course of action.
• Autonomy requires the nurse always respects
a client’s right to make decisions even when
those choices seem to the nurse not to be in
the client’s best interest.
10. Moral principles – Non - maleficence
• It is the duty to “do no harm”. Ham can mean
intentionally causing harm, placing someone
at risk of harm, and unintentional causing
harm.
• Unintentional harm occurs when the risk
could not have been anticipated.
11. Moral principles – Beneficence
• It means the doing of good, active goodness
or kindness, and charity.
• Nurses are obligated to do good, that is, to
implement actions that benefit clients and
their support persons.
12. Moral principles – justice
• Justice is referred to as fairness.
• Fairness requires that we treat people in equal
situations in an equal manner.
• Nurses often face decisions in which a sense
of justice should prevail.
13. Moral principles – fidelity
• It means to be faithful to agreements and
promises. Nurses have responsibilities to clients,
employers, government and society.
• For example, nurses often make promises such as
“I’ll be right back with your pain medications” or
“I’ll find out for you”. Clients take such promises
seriously and nurses are obligated to respond
within an appropriate time frame.
14. Moral principles – veracity
• It refers to telling the truth.
• Although it seems straightforward, in practice
choices are not always clear. Does a nurse tell
the truth when it is known that it will cause
harm? Does a nurse tell a lie when it is known
that the lie will relieve anxiety and fear?
• Lying to sick or dying people is rarely justified.
(McPherson & Stakenberg, 2012)
15. Accountability & responsibility
• Accountability means the state of being
answerable for one’s decisions and actions
and it cannot be delegated.
• Responsibility refers to the obligation that an
individual assumes when undertaking to carry
out planned/delegated functions.
The individual who authorises the delegated
function retains accountability.
16. Think about these questions…
Consider your past, your upbringing and life
experiences to date and the impact they have on
how you think. What are the influences, for
example, of your political beliefs, your belief in the
existence of God, whether you believe in aliens,
astrology or fate? Why do you believe what you do?
Who and what has influenced you? Do these same
influences have a bearing on the way you make
ethical choices? Are these influences always
rational?
17. Factors which influence ethical
decision making – cont.
• The law
• Social etiquette/norms
• Professional codes
• Religion
• Experiences
• Practicality
• Subjective/relative
18. The goal of ethical decisions
• Is to reach a mutual, peaceful agreement that
is in the best interests of client; reaching the
agreement may require discussion and
clarification of values.
19. Advocacy
• Advocacy refers to the act of pleading for,
supporting, or recommending; active espousal.
• An advocate is one who expresses and defends
the cause of another.
• The overall goal of a client advocate is to protect
the client’s right. An advocate informs clients
about their rights and provides them with the
information they need to make informed
decision.
20. Everyday ethical issues in nursing
• The moral boundaries of nursing (being “in
relationship” or “detached observes choosing from behind a veil of
ignorance”).
• Catalysts to moral action (‘experiential triggers’ such as ‘the
look of suffering in a patient’s eyes’, as opposed to abstract moral rules
and principles).
• Ethical decision-making process (which tend to be
collaborative, communicative, communal and contexualised, rather than
independent, private, individual, solo and decontextualised).
• Operational moral values (e.g., sympathy, empathy,
compassion, kindness, human understanding, and a desire ‘to do the best
we can’, rather than an obsession to ‘do one’s duty’).
21. Everyday ethical issues in nursing –
cont.
• Barriers to ethical practice (which tend to be structural
rather than knowledge-based, e.g., organisational norms focusing
compliance with the present situation, and negative attitudes and a lack of
support from co-workers and managers)
• Need for cathartic talking (e.g., ‘talking through’ moral
concerns in a safe and supportive environment to help relieve the distress
that so often arises as a result of trying to be moral in a world that
appears to be growing increasingly amoral)
(Daly et al., 2014)
22. Everyday ethical issues in nursing –
cont.
The literature showed that nurses are not often troubled by the
bioethical issues (abortion, euthanasia, organ transplantation, etc.),
but by more fundamental issues of the following:
• How to help a patient in distress in the ‘here and now’.
• How to stop ‘things going bad for a patient’
• How to best support a relative or chosen carer during times of
distress and when the ‘system’ appears to be against them
• How to make things ‘less traumatic’ for someone who is suffering
• How to reduce the anxiety and vulnerability of the people being
cared for
• Where nurses can get help for their own distress, and
• How to make a difference in contexts where indifference to the
moral interests of others is manifest
(Johnstone, 2009, as cited in Daly et al., 2014, p. 161).
23. A scenario
Mr L, a 75-year-old man, is hospitalised with multiple fractures
and lacerations caused by a motor vehicle accident. His wife,
who was killed in the accident, was taken to the same hospital.
Mr L who had been driving the car, constantly questions her
primary nurse about his wife; however, the surgeon has told the
nurse not to tell Mr L about the death of his wife; however, the
surgeon does not give the nurse any reason for these
instructions.
The nurse expresses concern to the Nurse Unit Manager, who
says the surgeon’s orders must be followed – that the surgeon
will decide when Mr L should be told. However, the nurse is not
comfortable with this and wonders what should be done.
(Source: Mcpherson & Stakenberg, 2012, p. 99)
24. Nursing actions
• Identify moral aspects.
• Gather relevant facts that relate to the issue.
• Determine ownership of the decision.
• Clarify and apply personal values.
• Identify ethical theories and principles
• Identify applicable laws or agency policies
• Use competent interdisciplinary resources
• Develop alternative actions and project their outcomes on the client and
family.
• Apply nursing codes of ethics to help guide actions.
• For each alternative action, identify the risk and seriousness of
consequences for the nurse.
• Participate actively in resolving issues.
• Implement the action.
• Evaluate the action taken.
25. Considerations
• The alternative actions are to tell the truth or
withhold it. The moral principles involved are
honesty and loyalty. These principles conflict
because the primary nurse wants to be honest
with Mr L without being disloyal to the surgeon
and the nurse unit manager. The nurse will weigh
up reasons in making a freely and consciously
chosen decision. The decision will probably be
affected by feelings of concern for Mr L and a
context that includes the surgeon’s incomplete
communication with the client and the nurse.
26. References
• Berman, A., Snyder, S., Levett-Jones, T., Dwyer, T.,
Hales, M., Harvey, N., … Stanly, D. (2012). Kozier
and Erb’s Fundamentals of Nursing (2nd ed.).
Frenchs Forest, NSW: Pearson.
• Daly, J., Speedy, S., & Jackson, D. (2014). Contexts
of nursing (4th ed.). Chatswood, NSW: Churchill
Livingstone, Elsevier.
• McPherson, C., & Stakenberg, S. (2014). Values,
ethics and advocacy. In A. Berman et al.(Eds.),
Kozier and Erb’s Fundamentals of nursing (pp. 89-
107). Frenchs Forest, NSW: Pearson.
Editor's Notes
1.Utilitarianism views a good act as one that brings the most good and the least harm to the greatest number of people. E.g., if a client’s behaviour was disturbing other clients, the nurse would focus on alleviating the behaviour of the disruptive client in order to minimise the impact on the other clients. This is called the principle of utility. This approach is often used in making decisions about the funding and delivery of health care. Teleological theories focus on issues of fairness as an end result.
2. deontological theories - the morality of an action is determined not by its consequence but by whether it is done according to an impartial, objective principle. E.g., “do not lie”, a nurse might believe that he or she should tell the truth to a dying client, even though the doctor has given an instruction no to do.
3. Relationship-based (caring) theories judge actions according to a perspective of caring and responsibility. Principles-based theories stress individual right, but caring theories promote the common good or welfare of the group.
. However doing good can also pose a risk of doing harm, e.g., advising the patient about a strenuous exercise program to improve general health, but not if it is know that this may impact some way on the health or wellbeing of the client.
For example, a nurse making home visits finds one client tearful and depressed, and knows she could help by staying for 30 minute to talk. However, that would take time from her next client, whose blood glucose levels are out of control. The nurse will need to carefully weigh up the facts in order to prioritise the time given to each patient.
Nurses often make promises such as “I’ll be right back with your pain medications” or “I’ll find out for you”. Clients take such promises seriously and nurses are obligated to respond within an appropriate time frame.
e.g., nurses brought up in the Roman Catholic tradition, their faith will impact greatly on the negativity they might feel about abortion. This negativity may contrast vastly with the opinions and beliefs of individuals brought up at the same time in the same community, but who are not Catholic, and who are perhaps more liberal in their view of abortion. The interesting question here is not whether one of these points of view is right or wrong; the important question is how the different influences on how they see the world lead them to their viewpoint. It is important to discover whether or not they allow this viewpoint to influence the way in which they work and how they treat patients-expressly in this example women who are planning, are undergoing, or who have had a planned abortion.
Law law is about protecting people in society and about attaining justice for many. Law exists in a written form as set guidelines for behaviour, ethics does not. There is not a law for everything, but there is an ethical response to all situations and activities which involve human activity.
Social etiquette/norms the right behaviour (social etiquette) and the right understanding (social norm) will be arrived at over a period of time as a result of the influence of the input of the various members of society.
we are influenced to a greater or lesser extent by the fact that other people are watching what we do.
Professional codes to provide a general basis for action and ways of behaving.
Religion . For many people of faith, their religion is the first port of call for an answer to a moral or ethical question.
the first issue is being able to justify the imposition of our own religious views on other people who either have no religious belief or are of a different faith. This may lead to tensions with respecting individual autonomy and the nursing philosophy of person-centred care. This religious bias may manifest in the ways in which we make decisions which may not be in the pt’s best interests, but which rather represent the healthcare professional’s own religious point of view. Second, as healthcare professionals, we may not agree with the religious convictions of others and may regard the decisions they make as inferior to those we might make. The classic example is that of the Jehovah’s Witness who refuses a blood transfusion even though it will in all probability lead to that person’s death.
5. Experiences- to provide us opportunities for us to reflect on, identifying ways of working which are congruent with our values. That is to say, we can use our bank of experience to help guide how we might adapt what we do and how we might act in the future.
6. Practicality Ethics is grounded in the real world and the decisions we take, especially as nurse, impact real people. Ethics does not occur in a vacuum and is therefore not just for discussion.
7. Subjectivity refers to how different people may view the same occurrence, such as a ethical dilemma, in different ways, while relativity refers to the ethicalness of a decision or action being based in the exact context.
