Transcript Ethical Decision

Health Care Core Curriculum
Healthcare Ethics
Dede Carr, BS, LDA
Karen Neu, MSN, CNE, CNP
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Competencies:
 Describe aspects of ethical decision-making
in health care.
1. Define ethics
2. Define the Code of Ethics
3. Explain the purpose of the Code of Ethics
4. Identify eight guiding principles in ethics
5. Identify steps/framework for ethical
decision-making
6. Discuss the difference between legal
“guidelines” and ethical decision-making
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The term ethics has several meanings in
common use:
 A method of inquiry that helps people to
understand the morality of human behavior
(study of morality)
 The practices or beliefs of a certain group
(medical ethics, nursing ethics)
 The expected standards of moral behavior of a
particular group as described in the group’s
formal code of professional ethics.
(Ramont & Niedringhaus, p. 38)
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Ethics: The study of conduct and character;
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(Potter & Perry, p. 314)
concerned with determining what is good or
valuable for individuals, for groups of
individuals, professions, and for societies strive
to meet.
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Acts that are ethical reflect a commitment to
standards beyond personal preferences--standards that individuals, professions, and
societies strive to meet.
When it comes to decision-making in health
care, however differing values between
individuals cause intense disagreement about
the right thing to do.
(Potter & Perry, p. 314
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Understandable conflict occurs between health
care providers, families, clients, friends and
people in the community about the right thing
to do when ethics, values, and decisions about
health care collide.
(Potter & Perry, p. 314)
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Bioethics is ethics as applied to life
(decisions about abortion or euthanasia).
Nursing ethics refers to ethical issues that
occur in nursing practice.
(Ramont & Niedringhaus, p. 38)
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Morality (or morals) is similar to ethics and
many people use the terms interchangeably.
Morality usually refers to private, personal
standards of what is right and wrong in
conduct, character, and attitude.
Sometimes the first clue to the moral nature of
a situation is an aroused conscious or an
awareness of feelings, such as guilt, hope, or
shame.
(Ramont & Niedringhaus, p. 38)
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Another indicator is the tendency to respond to
the situation with words such as ought, should,
right, wrong, good, and bad.
Moral issues are concerned with important
social values and norms; they are are not about
trivial things.
(Ramont & Niedringhaus, p. 38)
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Moral principles are statements about broad,
general, philosophical concepts such as
autonomy and justice.
Principles are useful in ethical discussions
because even if people disagree about which
action is right in a situation, they may be able to
agree on the principles that apply.
(Ramont & Niedringhaus, p. 38)
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Such agreements can serve as a solution that is
acceptable to all parties.
Ethical issues are looked at differently among
people of different cultures; one must consider
these differences when providing health care.
(Ramont & Niedringhaus, p. 38)
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Respect & Dignity for Human Life
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Autonomy (Self-Determination
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Nonmaleficence (Do no harm)
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Beneficence (Do good)
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Justice (Fairness)
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Fidelity (Keeping promises)
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Veracity (Truth telling)
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Confidentiality (Be discreet with privileged
information)
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Responsibility
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Accountability
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Respect for each client as a unique individual is
an ethical principle. This uniqueness is
demonstrated in differences in age, race,
religion, gender, culture, sexual preference,
attitudes, background, and responses to
illness.
(Hegner, Acello, & Caldwell, p. 37)
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You may find the differences make the patient
so different also making dealing for the patient
so challenging or difficult.
If you respect each patient as a valuable
person, you learn to accept and work with each
one in the best way possible.
(Hegner, Acello, & Caldwell, p. 37)
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All residents and patients have the right to be
respected and treated with dignity.
Dignity affords the resident pride and selfrespect. (Webster’s New World College Dictionary, 2009)
Remember that residents have been fully
functional beings before getting frail and sick.
They do not need to be talked to with “baby
talk.” This is disrespectful not only to the
resident, but to the family as well.
(Alvare, Fuzzy, & Rymer)
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Dignity is an important issue when working with
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residents and patients.
Be sure to knock on the door before entering a
room.
Keeping the resident covered during care is
very important.
Think about how one would want to be treated.
Maintaining privacy means pulling the curtain
between beds and closing the curtains or
blinds in the window.
(Alvare, Fuzzy, & Rymer)
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Autonomy (Self-Determination) refers to the right
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to make one’s own decisions.
Healthcare workers follow this principle by
recognizing that each client is unique, has the
right to be what that person is, and has the right
to choose personal goals.
(Ramont & Niedringhaus, p. 39)
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Honoring the principle of autonomy means that
the healthcare worker respects a client’s right to
make decisions even when those choices seem
not to be in the client’s best interest.
It also means treating others with consideration.
In the healthcare setting, this principle is
violated, for example, when the healthcare
worker disregards a client’s report of the severity
of his/her pain. (Ramont & Niedringhaus, p. 39)
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Autonomy (Self-Determination) Examples:
The consent that clients read and sign before
surgery illustrates this respect for autonomy.
The signed consent ensures that the health care
team obtained permission from the client before
proceeding with the surgery.
(Potter & Perry, p. 314)
(Minnesota Department of Health)
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Autonomy is reflected in the information about
rights during individuals’ stay in a facility or
throughout their course of treatment and
maintenance in the community as stated in the
Patient’s Bill of Rights (document signed by
clients/families).
(Minnesota Department of Health)
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Certain concepts act against autonomy.
Paternalism refers to a concept wherein healthcare
providers make choices on behalf of the patient
under the misguided notion that said healthcare
provider knows “what is best” for the patient.
It may be the family members who are acting in a
paternalistic manner and deciding what is best
for the patient without allowing the individual to
make his or her own choices in the matter.
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We appropriately manifest paternalism when we
tell a six year old child that he may not play with
matches.
We are guilty of inappropriate paternalism when
we make decisions on behalf of patients because
we believe that we are more knowledgeable than
is the patient in matters concerning that
patient’s health.
(Brenneman, p. 2)
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Beneficence means “doing good,” positive actions
to help others; the encourages the urge to do good
for others.
Healthcare workers are obligated to do good, that
is implement actions that benefit clients and their
support persons and are more important than selfinterests.
◦ For example, a child may ask for a pill to be
crushed and mixed with a food, even though you
know the child is able to swallow the pills whole.
Your commitment to do good for others guides
you to comply with the child’s wishes, even if you
are having a busy day.
(Potter & Perry, p. 314)
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However, doing good can also pose a risk of
doing harm.
◦ For example, a nurse may advise a client
about a strenuous exercise program to
improve general health, but should not do so
if the client is at risk for a heart attack.
(Ramont & Niedringhaus, p. 39)
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Nonmaleficence is duty to “do no harm or hurt.”
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◦ This seems like a simple principle to follow,
but in reality is quite complex.
The healthcare worker tries to balance the risks
and benefits of a plan of care while striving to
do the least amount of harm possible.
Harm can mean intentional harm, risk of harm,
and unintentional harm.
(Ramont & Niedringhaus, p. 39)
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In healthcare, intentional harm is never
acceptable.
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However, the risk of harm is not always
clear.
◦ For example: A client may be at risk of harm
during an intervention that is intended to be
helpful. For example, a bone marrow transplant
procedure offers a chance at cure but the
process involves periods of suffering.
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Healthcare workers need to consider the
associated discomforts, taking into
consideration the suffering of the disease
itself causes the suffering that other
treatments will possible cause.
(Potter & Perry, p. 314)
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Justice refers to fairness.
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Healthcare providers strive for justice in health
care.
The term is often used in discussion about
healthcare resources. What constitutes a fair
distribution of resources is not always clear.
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◦ For example, in the US the number of candidates
awaiting liver transplants is around 93,000, far
more candidates than donors
(United Network for Organ Sharing [UNOS], as cited in Potter & Perry, p.
314)
◦ What is fair distribution of this scarce resource?
◦ Criteria set by a national multidisciplinary committee
make every effort to ensure justice by ranking recipients
according to need. This system remains preferable in the
US to the selling of organs for profit, which would favor
recipients with the most money and preferable to a
distribution by lottery, which would result in random
distribution without regard to justice.
(Potter & Perry, p. 314)
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Examples of Justice at Work
 Use supplies responsibly to avoid waste
 Do work assigned to you and your fair share as a
team member
 Treat all patients equally and fairly regardless of
age, race, or religion
 Give a fair share of work for a fair share of wages
 Give nursing care on the same level to all patients
regardless of their racial or religious beliefs.
 Show equal courtesy and respect to all patients.
(Alvare, Fuzzy, & Rymer)
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Fidelity means to be faithful to agreements and
promises.
By the virtue of their responsibilities as
professional care givers, healthcare workers have
responsibilities to clients, employers, the
government, and society, as well as themselves.
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Healthcare workers often make promises such as
“I’ll be right back to assist you with your bath” or
“I’ll find out for you.”
Clients take these promises seriously, and so
should healthcare workers.
(Ramont & Niedringhaus, p. 39)
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Fidelity refers to the agreement to keep promises.
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A commitment to fidelity supports the reluctance
to abandon clients, even when disagreement
occurs about decisions that a client makes.
The standard of fidelity also includes an obligation
to follow through with care offered to clients.
If you tell the client that you plan to fix her hair
after her bath and shampoo, the standard of
fidelity encourages you to follow through with your
plan.
(Potter & Perry, p. 314)
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Veracity refers to telling the truth. Although this seems
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straightforward, in practice, choices are not always
clear.
Should a healthcare worker tell the truth when it is
known that it will cause harm?
Does a healthcare worker tell a lie when it is known
that the lie will relieve anxiety and fear?
The loss of trust in the healthcare worker and anxiety
caused by not knowing the truth, for example, usually
outweigh any benefits derived from lying. Lying to
sick or dying people is rarely justified.
(Ramont & Niedringhaus, p. 39)
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Code of Ethics: a set of guiding principles that all
members of a profession accept; a collective
statement about the group’s expectations and
standards of behavior, reflects the group’s moral
judgments over time, & works as a standard for
their professional actions.
Codes of Ethics serve as guidelines to assist
professional groups when questions arise about
correct practice or behavior.
(Potter & Perry, p. 315)
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Every person has a right to a continuity of good
quality Health Care without discrimination and
within the limits of the resources, manpower and
competence available for health and medical care.
In the course of such care, human dignity,
convictions, integrity, individual needs and culture
shall be respected.
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1.
2.
3.
4.
5.
6.
Inform the public about the minimum
standards of the profession and help them
understand professional healthcare/nursing
conduct.
Provide a sign of the profession’s commitment
to the public it serves.
Outline the major ethical considerations of the
profession.
Provide general guidelines for professional
behavior.
Guide the profession in self-regulation.
Remind healthcare workers of the special
responsibility they assume when caring for the
sick.
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The ethical code asserts that information
about patients is privileged and must not be
shared with others.
Discuss information only in appropriate
places, with the appropriate people, and
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International, national, state, and provincial
nursing associations have established codes
of ethics.
 The American Nurses Association (ANA)
established the first code of nursing ethics
decades ago and reviews and revises the code
regularly to reflect changes in practice.
Basic principles remain constant, however:
* Responsibility
* Confidentiality
* Accountability
* Advocacy
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Ethical problems in healthcare are due to social
and technological changes and healthcare
workers’ conflicting loyalties and obligations.
Social Changes: Women’s movement, growing
consumerism, large number of uninsured , high
cost of health care, and workplace redesign
under managed care—raise issues about fairness
and allocation of resources (justice).
(Ramont & Niedringhaus, pp. 39-40)
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Technology: monitors, ventilators, parenteral
feedings, (growth of premature infants), prolong
biological life
Who should be treated—everyone, only if they
can pay, only those who have a chance to
improve?
(Ramont & Niedringhaus, pp. 39-40)
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Conflicting Loyalties & Obligations
Healthcare workers, especially nurse experience
conflicts among their loyalties and obligations to
clients, families, physicians, employing
institutions, and licensing bodies.
Clients may conflict with institutional policies,
physician preferences, needs of the client’s
family, or even laws of the state.
(Ramont & Niedringhaus, p. 40)
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According to the codes of ethics, healthcare
workers first loyalty is to the client. For example,
a nurse may think that a client needs to be told a
truth that others have been withholding; but this
might damage the client-physician relationship,
in the long run causing harm to the client rather
than the intended good.
(Ramont & Niedringhaus, p. 40)
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Responsible ethical reasoning is rational and
systematic; should be based on ethical principles
and codes rather than on emotions, intuition,
fixed policies, or precedent. (Precedent is an
earlier similar occurrence.)
Good decision is in client’s best interest and
preserves the integrity of all involved.
(Ramont & Niedringhaus, p. 40)
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The healthcare worker must weigh competing
factors when making ethical decisions because
of the ethical obligations to clients, the
employing agency, and to physicians.
Because several people are involved in ethical
decision-making, communication and
compromise are important skills for all health
professionals.
Integrity-preserving compromises are likely
collaborative decision-making.
(Ramont & Niedringhaus, p. 40)
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Ethical problems nurses encounter most frequently:
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Cost-containment issues that jeopardize client
welfare and access to healthcare (resource
allocation)
Allocation of Health Resources
Allocation of healthcare goods and services
(organ transplants, artificial joints, services of
specialists)
(Ramont & Niedringhaus, p. 42)
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Nursing care is also a health resource. Most
institutions have been implementing “workplace
redesign” in order to cut costs. As a result,
nursing units are staffed with fewer nurses and
more unlicensed care givers.
Nurses must continue to look for ways to balance
economics and caring in the allocation of health
resources.
Breaches of confidentiality (computerized
information management)
Use of advance directives
Informed consent and procedures
(Ramont & Niedringhaus, p. 42)
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Ethical problems nurses encounter most
frequently:
Issues in the care of HIV/AIDS clients: social
stigma of AIDS, such as association of HIV/AIDS
with sexual behavior, prostitution, illicit drug
use, inevitable physical decline & death
(Healthcare workers have conflicting feelings of
anger, fear, sympathy, fatigue, helplessness,
self-enhancement; confidentiality issues; testing
HIV status
(Ramont & Niedringhaus, pp. 40-41)
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Abortion: debate between the sanctity of life
against the principle of autonomy & woman’s
right to control her own body (healthcare
workers have no right to impose their values on
clients); abortion laws provide specifics
Organ transplantation: allocation of organs,
selling of body parts, consent, clear definition of
death, conflicts of interest between potential
donors and recipients, person’s religious beliefs
(Ramont & Niedringhaus, pp. 40-41)
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End-of-life decisions:
Euthanasia: “mercy killing” or the “good death”
Active euthanasia involves actions to directly bring about the
client’s death, with or without client consent.
◦ Example: administration of lethal medication to end the client’s
suffering
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Active euthanasia includes assisted suicide or giving the client
the means to kill themselves if they request it (providing the
pills or weapon).
◦ Both euthanasia and assisted suicide are in violation of the code of
ethics.
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Passive euthanasia involves the withdrawal of extraordinary
means of life support, such as removing a ventilator or making
a client a “no code” “do not resuscitate.”
◦ The legality of passive euthanasia depends on the laws of a particular
jurisdiction and/or facility, even though not a violation of the ANA
code.
(Ramont & Niedringhaus, p. 41)
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End-of-Life Decisions
Termination of Life-Sustaining Treatment
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Antibiotics, organ transplants, and technology advances
(ventilators) help to prolong life, but not necessarily to restore
health.
Clients may have advance directives to provide their healthcare
wishes.
There is no ethical or legal distinction between the withholding
or withdrawing of treatments for the healthcare workers.
It’s more difficult for nurses to withdraw treatment than to
decide not to begin treatment initially.
To withdraw treatment is not to withdraw care, so healthcare
workers must ensure that sensitive care & comfort measures
are given as the client’s illness progresses.
(Ramont & Niedringhaus, pp. 41-42)
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End-of-Life Issues
Withdrawing or Withholding Food & Fluids
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It is generally accepted that providing food & fluids is part of
ordinary nursing practice and therefore, a moral duty.
However, when food and fluids are administered by tube to a
dying patient, or are given for a long period of time to an
unconscious client who is not expected to improve, then some
consider it to be an extraordinary, or heroic, measure.
A nurse is obligated to withhold food and fluids when it is
more harmful to administer them than to withhold them. In
addition, “It is morally as well as legally permissible for nurses
to honor the refusal of food and fluids by competent patients
in their care” (ANA, p. 3, as cited in Ramont & Niedringhaus, p. 42).
Nurses Code of Ethics support this position through the nurse’s role
as a client advocate and through the moral principle of autonomy.
(Ramont & Niedringhaus, p. 42).
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Advocacy refers to the support of a cause.
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Healthcare workers advocate for the health, safety,
and rights of the client.
Safeguard the client’s rights to physical and auditory
privacy
◦ For example, one should find a private place for discussion
with the client’s health care provider about the results of the
client’s diagnostic testing.
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As a client advocate, follow institutional policies and
procedures to report any occurrence of incompetent,
unethical, illegal, or impaired practice by any
healthcare member that has potential to affect client
health or safety.
(Potter & Perry, p. 314)
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The overall goal of the client advocate is to protect
client’s rights.
Being an effective client advocate is involves:
Being assertive
Recognizing that the rights and values of client’s
and families must take precedence when they
conflict with those of healthcare providers
Being aware that conflicts may arise over issues that
require consultation, confrontation, or negotiation
between the healthcare worker and administrative
personnel or between the nurse and the physician
(Ramont & Niedringhaus, p. 42)
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The client is a holistic, autonomous being who has
the right to make choices and decisions.
Clients have the right to expect a healthcare
worker-client relationship that is based on shared
respect, trust, and collaborating in solving problems
related to health and healthcare needs, and
consideration of their thoughts and feelings.
Clients are responsible for their own health.
It is the healthcare provider’s responsibility to
ensure the client has access to healthcare services
that meet health needs. (Ramont & Niedringhaus, p. 42)
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The word responsibility refers to a willingness to respect
obligations and to follow through on promise. (Potter &
Perry, 2009, p. 315)
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As a healthcare worker, you are responsible for your
actions. Responsibility refers to “the specific
accountability or liability associated with the performance
of duties of a particular role.”
(Berman et al., p. 85)
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You are an active member of the healthcare team and
have an active role in shaping healthcare practice, rather
than a passive role.
Continue to be competent to practice by being
dependable, accountable, and responsible to follow
through with assigned tasks, promises, etc.
Stay current with new equipment, practices, and
knowledge by attending required in-services.
(Potter & Perry, p. 315)
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Accountability refers to the ability to answer for one’s
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own actions to self and others.
One should ensure that one’s professional actions
are explainable to your clients and your employer.
Health care institutions play a role in accountability too, by
monitoring individual and institutional compliance with
national standards established by The Joint Commission
(TJC) and American Nurses Association (ANA).
(Potter & Perry, p. 315)
The following slides are examples of standards for
monitoring and protecting nursing practice.
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Confidentiality (Respecting Privileged Information)
The obligation to observe the privacy of
another and to hold certain information in
strict confidence.
There are time when the presumption against
disclosing information must be overridden. For
example, health care workers are required by
law to report certain cases, such as drug abuse
in employees, elder abuse, or child abuse or
neglect. (Marquis & Huston, p. 76)
Concept of confidentiality in healthcare is
widespread in US (Federal legislation-HIPAA)
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Federal legislation (HIPAA ) mandates the
confidential protection of clients’ personal health
information.
 It defines the rights & privileges of clients for
protection of privacy without diminishing access to
quality care and establishes fines for violation.
◦ For example, you cannot copy or forward medical records
without a client’s consent. You cannot share health
information including laboratory results, diagnosis, and
prognosis with others without specific client consent, unless
the information is necessary in the course of providing care.
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(Marquis & Huston, p. 67)
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Communication about a client should only take
place in a private setting.
◦ When reporting to your supervisor or team
leader, go to a private place rather than in the
hall or open nurse’s station area where visitors,
clients, or others can hear what is being said.
(Marquis & Huston, p. 67)
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Client information may not be disclosed to
unauthorized individuals or family members who
request it or individuals who call on the phone.
Many hospitals use a code system in which information
is only disclosed to individuals who can provide the
code.
The healthcare worker should ask any individual
inquiring about a client’s status for the code & disclose
information only when an individual can give the code.
(Marquis & Huston, p. 76)
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When medical records are computerized, computer security
measures such as special access codes for all authorized
users and computer “firewalls” protect systems from
unauthorized access. (US Department of Health & Human Services,
as cited in Potter & Perry, p. 315)
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Hospital information systems provide a
centralized electronic source for information
and allow primary care providers to pull
together client information from a variety of
sources.
Strategies to protect client information
Using passwords for access to electronic
information
(Marquis & Huston,)
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Prohibiting the sharing of passwords, thus
preventing unauthorized access to confidential
information.
Allowing access of information only to health
team members directly involved in a client’s
care.
Monitoring for breaches in electronic
confidentiality and reporting infractions to
appropriate officials.
Securing placement of paper-based charts to
prohibit unauthorized viewing.
(Marquis & Huston)
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Although the client
owns the information in
the medical record, the
actual record belongs
to the facility that
originally made the
record & is storing it.
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Ethical theory examines the different
philosophies, systems, ideas, and principles
used to make judgments about what is right and
wrong and good and bad. For example:
◦ A person who believes that life is sacred may not be
able to sanction the removal of life support services on
a client with a severe head injury.
◦ A person who believes that life begins as conception
may not support the use of birth control methods that
prevent implantation (intrauterine devices, morning
after pill).
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(Marquis & Huston)
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Ethical dilemmas occur when the choice available
include only undesirable alternatives.
Ethical decision-making is the use of a
systematic approach that enhances decisionmaking and subsequent satisfaction with the
decision.
(Marquis & Huston)
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The ability to provide an ethically supportable
rationale for decisions and actions is
foundational to professional healthcare
practice and the integrity of healthcare
workers.
The first task is to identify whether a situation
presents as an ethical dilemma or problem
recognizing that the healthcare worker-client
relationship always has ethical dimensions
whether problematic or not.
(Davis, Aroskar, Liaschenko, & Drought p. 47)
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In other words, every healthcare worker-client
relationship has the potential to be an ethical
problem or dilemma.
(Davis, Aroskar, Liaschenko, & Drought, p. 47)
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The existence of a conflict of values
Obligations, loyalties, interests, or
Needs in a patient care situation, such as
◦ Disagreement about treatment between health
professionals and patients or health care team
members and patients’ families and
◦ Ethical principles or values are at stake, such as
respect for patient autonomy, doing the least harm,
or the values of caring and patient advocacy; and the
situation involves the feelings and values of all key
persons involved in the situation. (Davis, Aroskar, Liaschenko, &
Drought, p. 47)
71
 Once a situation is identified that constitutes
an ethical problem consideration for the
following elements assists with the
discussion, analysis, and development of
ethically supportable decisions.
(Davis, Aroskar, Liaschenko, & Drought, p. 47)
72
1.
2.
3.
4.
5.
Review the overall situation to identify what is
going on.
Identify significant facts about the client,
including the medical, social history, decisionmaking capacity, existence of an advance
directive for treatment.
Identify the parties or stakeholders involved in
the situation or affected by the decision (s) that
is made.
Identify relevant legal data
Identify specific conflicts of ethical principles or
values.
(Davis, Aroskar, Liaschenko, & Drought, p. 47)
73
6. Identify possible choices, their intent, & probable
consequences to the welfare of the client/clients as
the primary concern.
7. Identify practical constraints, i.e., legal, organizational,
political, economic.
8. Make recommendations for action that are determined
to be ethically supportable recognizing that the
possible choices often have positive and negative
aspects.
9. Take action if your are the decision-maker and
implementer of the decision (s) made.
10. Reviews and evaluate the situation after action is
taken in order to determine what was learned that will
help in resolution of similar situations in client care
and related policy development. (Davis, Aroskar, Liaschenko, & Drought, p.
47)
74
Ethical decisions can be made using the following
1.
2.
3.
4.
5.
6.
7.
steps (This is the compact version):
Identify the ethical problem.
Analyze the causes and consequences of the
problem.
Identify possible solutions.
Evaluate each solution in relation to acceptable
and unacceptable consequences.
Select the perceived appropriate solution.
Implement the solution.
Evaluate.
(Marquis & Huston)
75
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