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Course: Fundamentals of Nursing

Topic: Ethical Concepts in Client Care

The Nurses International Community

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COPYRIGHT

NI Privacy Policy and Terms of Use.

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Module Goals

Learners will be able to:

Define the basic principles of ethics
Explain the ethical principles of client care
Apply ethical decision making to ethical dilemmas

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Basic Principles of Ethics

There are four basic principles of ethics that apply to medical practice and client care (Beauchamp & Childress, 2019; Cherie et al., 2005):

Autonomy - a person’s right to make their own decisions
Nonmaleficence - do no harm
Beneficence - acting for the good or benefit of others
Justice - fairness and equal treatment of all individuals

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Autonomy

Self-determination
In order for a person to have autonomy, two important conditions must be met (Summers, 2014):

Person must be competent to make decisions for themselves
Person must be free of coercion in making decisions

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Nonmaleficence

In order to “do no harm” we have to determine what harm is
In the clinical setting, harm is generally considered anything that worsens the condition of the client (Summers, 2014)
Deciding whether something is harmful is complicated in medicine because medical interventions often involve both harm and good, usually described as risks and benefits
Beneficence and nonmaleficence can be applied together to compare harms done, harms prevented or removed, and good promoted to decide if an intervention is in a client’s best interest (Snyder & Gauthier, 2008)

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Beneficence

Beneficence involves acting with kindness, compassion, and understanding
In medicine, beneficence also involves providing benefit to clients by promoting and protecting their wellbeing (Bester, 2020)
Following this principle means not just refraining from doing harm, but actually taking steps to do good
Acting with beneficence requires the ability to see that everyone has worth

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Justice

There are two main categories of justice: procedural justice and distributive justice (Summers, 2014)
Procedural justice is concerned with whether fair procedures are in place and being followed
Distributive justice is concerned with the distribution of resources

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Critical Thinking Question

There is more to justice than just being fair. What aspects of justice are especially challenging in healthcare?

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Ethical Principles of Client Care

There are many frameworks and codes of ethics that have been developed to help nurses apply ethical principles to client care. One of the most widely used is the International Council of Nurses (ICN) Code of Ethics for Nurses (2012), which provides guidelines for how a nurse should interact with people, co-workers, nursing practice, and the profession.

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ICN Code of Ethics for Nurses

Nurses and People

Primary responsibility is to people requiring nursing care
Promotes environment that respects rights, values, customs, and spiritual beliefs of individual, family, and community
Ensures client receives all the information they need to provide informed consent for their care
Uses careful judgement when disclosing personal client information
Advocates for equity and social justice
Demonstrates professional values like trustworthiness, integrity, respectfulness, and compassion

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ICN Code of Ethics for Nurses

Nurses and Practice

Personally responsible for good practice, and promotes safe care by staying up to date with competencies.
Stays healthy to preserve ability to provide client care.
Uses good judgement about level of competence when accepting and delegating responsibilities.
Ensures use of technology and scientific advances are safe and preserve client rights.
Promotes culture of ethical behavior and open discussions.

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ICN Code of Ethics for Nurses

Nurses and the Profession

Takes major role in deciding and implementing standards for nursing practice, research, and education.
Helps develop research-based knowledge that supports evidence-based practice.
Develops and maintains core professional values.
Works with professional organizations to create positive, safe, equitable working conditions for nurses.
Contributes to ethical organizational environment and challenges unethical practices.

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ICN Code of Ethics for Nurses

Nurses and Co-Workers

Maintains collaborative and respectful relationship with co-workers.
Takes appropriate action to protect anyone whose health is endangered by a co-worker.
Helps to support and guide co-workers in advancing ethical conduct.

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Critical Thinking Question

How are the basic principles of ethics reflected in the ICN Code of Ethics for Nurses?

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(All quotes are from the ICN Code of Ethics for Nurses)

Autonomy - “The nurse ensures that the individual receives accurate, sufficient and timely information in a culturally appropriate manner on which to base consent for care and related treatment” (p.2)

Nonmaleficence - “The nurse carries personal responsibility... for maintaining competence by continual learning” (p.3) “The nurse, in providing care, ensures that use of technology and scientific advances are compatible with the safety…” (p.3) “The nurse uses judgement regarding individual competence when accepting and delegating responsibility” (p.3) “The nurse takes appropriate action to safeguard individuals, families and communities when their health is endangered by a co-worker or any other person” (p.4)

Beneficence - “Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health and to alleviate suffering” (p.1) “The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations” (p.2) “The nurse contributes to an ethical organisational environment and challenges unethical practices and settings” (p.4)

Justice - “The nurse advocates for equity and social justice in resource allocation, access to health care and other social and economic services” (p.2)

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Examples of Current Ethical Issues

Do Not Resuscitate (DNR)
“Do everything possible” technology
Pharmaceutical industry practices
Gender-selection (“designer babies”)
Organizational resources for health care
Research ethics

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Ethical Issues: Do Not Resuscitate (DNR)

Do Not Resuscitate Orders

The client is usually incapacitated with little hope of recovery
Physician will consult with the family before writing a DNR order
Nurse has a duty to follow the order

Braddock III & Clark, n.d.

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Ethical Issues: Right to Refuse Treatment

A competent adult has the right to determine what does or does not happen to him or her.

Even if the refusal may or will result in death 1

Advance directive

Specifies what life-saving treatments he or she does or does not wish to have
Becomes effective when the client is incapacitated 2

Grace & Hardt, 2008
National Cancer Institute, n.d.

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Ethical Issues: Refusal to Treat

ANA (2015) Position Statement on ‘RISK AND RESPONSIBILITY IN PROVIDING NURSING CARE’:

Nurses have a duty to care for patients and are not at liberty to abandon them; however, nurses are challenged to thoughtfully analyze the balance of professional responsibility and risk, including moral obligations and options, in order to preserve the ethical mandates in situations of risk to the nurse or profession.’

‘Conscience-based refusals to participate exclude personal preference, prejudice, bias, convenience, or arbitrariness.….’

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Ethical Issues: Refusal to Treat

The nurse cannot refuse to care for a client because she disagrees with the decisions the client makes

Nurse does not have to participate in the procedure but cannot refuse to provide care after procedure

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Ethical Issues: Refusal to Treat

Royal College of Nursing (2021) states :

‘you cannot refuse to be involved in the care of patients because of their condition or the nature of their health problems. All blood and body fluids should be treated as infectious...

‘A patient may request a nurse or midwife of the same or different gender to carry out certain procedures. There is no legal right to this, however best practice would be to make reasonable efforts to support the patient's request. Special consideration should also be given to young people and those with mental capacity concerns.’

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Ethical Decision Making

Healthcare providers are frequently faced with ethical dilemmas. When it comes to making a decision, it helps to use an ethical decision-making model. There are many decision-making models, but we will focus on the guide to moral decision-making model and clinical ethics grid system described by Cherie et al. (2005).

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A Guide to Moral Decision-Making Model

This model is a multistep process that addresses many aspects of ethical decision making:

1. Recognize the moral dimension

Recognize that the decision being made has an ethical/moral aspect
An important clue includes conflicts between two or more values or ideals

2. Identify who is involved

Identify who has a stake in the decision
There are often more parties whose opinion should be taken into account than is immediately obvious

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A Guide to Moral Decision-Making Model

3. What values are involved?

Think through the values and ethical principles involved in the decision
Consider both your own and others values and ethical beliefs

4. Weight the benefits and burdens

Consider the benefits and burdens of the decision (positive and negative outcomes)

5. Look for similar cases

If there have been similar cases, what course of action was taken? Was it a good one?

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A Guide to Moral Decision-Making Model

6. Discuss with others

Discuss your decision with as many relevant people as you can
Ask for their opinions and the reasons behind them

7. Is the decision in accordance with legal and organizational rules?

Decide whether the decision is legal and meets the rules of the organization where the case is or for whom you work
Also consider whether the decision is in accordance with your profession’s code of ethics (for example, the ICN Code of Ethics for Nurses) and professional standards

8. Am I comfortable with this decision?

Ask yourself, if I carry out this decision, will I be comfortable telling others about it? Would I want others to follow my behavior?
Can I live with this decision?

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Clinical Ethics Grid System Model

This model helps to summarize the facts that must be considered along with ethical principles to make an ethical decision about a treatment in a clinical setting:

1.Medical history/current medical information

Client’s medical history and current diagnosis
Is problem acute, chronic, emergent, reversible?
What are the goals of treatment?

2.Client preference

What is the client’s preference after hearing and understanding all the benefits and risks of the treatment(s)

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Clinical Ethics Grid System Model

3. Quality of life

What are the client’s chances of having a normal quality of life with and without treatment?
Are there biases that might influence the provider’s evaluation of a client’s quality of life?

4. Contextual factors

Are there family issues that might influence treatment decisions?

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Case Study/What would the nurse do?

You are part of a healthcare team caring for a client who is a prisoner. The client has a fracture that requires surgery to retain function of the limb. However, because you are working in a resource poor environment, the team is split on whether or not the client should receive the surgery. Those against it say that according to certain distributive justice criteria surgical supplies should not be wasted on a member of society who is “not useful” while those who are for it say that the principle of beneficence requires the team to intervene. A team meeting is scheduled to discuss the situation. How could you use the guide to moral decision-making model to help reach a decision?

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Recognize the moral dimension: A clue that there is a moral/ethical aspect to the decision that needs to be made is that there is a conflict between values/ideals (distributive justice versus beneficence)
Identify who is involved: Some of the involved parties may be the client, possibly family members, the nurses caring for the client, and the surgeon
What values are involved: Justice (particularly distributive), beneficence, autonomy to a certain extent, values such as compassion, duty to client, equity, social justice etc. from professional standards of practice and codes of ethics for both physicians and nurses. Think about both your values/ethical beliefs and the values and ethical beliefs of the other involved parties.
Weight the benefits and burdens: Benefits of doing the surgery could include the client having better quality of life by keeping the function of their limb/the chance to be more productive upon release from prison if they have full use of the limb, upholding multiple ethical principles and values important in medicine etc. Burdens of doing the surgery could include using up limited resources, a financial burden to the client, family, or hospital, not making a decision that aligns with everyone’s distributive justice values etc.
Look for similar cases: Have there been other cases in resource poor environments regarding care of prisoners? If so, what decisions were made? What were the outcomes of those decisions?
Discuss with others: Listening to more opinions than just those intimately involved in the case can be very helpful. Some examples of other opinions to seek out could include mentors and other medical staff not involved in the case
Is the decision in accordance with legal/organizational rules: Think about the rules in your country regarding client care and distribution of resources. Are any of the decisions being discussed not legal? Are any of the decisions being discussed against the rules of the organization where the client is hospitalized? At this point, you should also think about whether the decision you want to make is in accordance with your profession’s code of ethics. For example, the ICN Code of Ethics for Nurses states that “The nurse advocates for equity and social justice in resource allocation, access to health care and other social and economic services” as well as being compassionate and advocating for vulnerable populations.
Am I comfortable with this decision: Only you can decide if you feel comfortable with your decision. Think about whether you would feel okay telling your mentors, other medical staff, and family about your decision. Are you okay with other people making the same decision or using your decision as an example in the future? Can you live with your decision or will it bother you for the rest of your life?

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Cultural Considerations

Different cultures have different cultural values that must be considered when applying ethical principles (Ludwick & Silva, 2000)
When taking care of clients from different cultures, the nurse should follow the ICN Code of Ethics for Nurses (2012) that states that nursing care is always respectful of and not limited by culture, race, or nationality.

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- An example of different cultural values that may affect the application of ethical principles is a culture that values individualism (individual rights are more important than those of the group) versus a culture that values collectivism (the loyalties of a person to the group is more important than the rights of the individual). While an individualistic culture would place a high value on the ethical principle of autonomy and view that principle as an individual client (or healthcare proxy) making the final decision regarding their care, a collectivist culture might not place as much value on autonomy or may view the principle differently since the family or community might normally make group decisions about client care.

- Some strategies to reduce ethical conflicts when caring for clients with different cultural values include (Ludwick & Silva, 2000):

1. Recognizing that values and beliefs differ both among different cultures and within the same culture

2. Learn as much as you can about the language, customs, beliefs and values of the cultural groups with which you have the most contact

3. Be aware of your own cultural values and biases, which helps to decrease cultural imposition and evaluating other cultures based on preconceptions arising from your own culture’s standards and customs

4. Be aware of biocultural differences that may present in the physical exam, in types of illness, and in health care practices

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Reference:

American Nurses Association. (2015, June). American Nurses Association Position Statement on Risk and Responsibility in Providing Nursing Care [PDF]. https://www.nursingworld.org/~4ad4a8/globalassets/docs/ana/riskandresponsibility.pdf

Beauchamp, T.L, & Childress, J.F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Bester, J.C. (2020). Beneficence, interests, and wellbeing in medicine: What it means to provide benefit to patients. The American Journal of Bioethics, 20(3), 53-62. https://www.tandfonline.com/doi/full/10.1080/15265161.2020.1714793

Braddock, C.H. & Clark, J.D. (n.d.). Do Not Resuscitate (DNAR) Orders. Department of Bioethics and Humanities, University of Washington. Retrieved on September 24, 2021 from https://depts.washington.edu/bhdept/ethics-medicine/bioethics-topics/detail/61

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Reference:

Cherie, A., Mekonen, A.H., & Shimselse, T. (2005). Lecture notes for nursing students: Introduction to professional nursing and ethics. Addis Ababa University. https://www.cartercenter.org/resources/pdfs/health/ephti/library/lecture_notes/nursing_students/ln_intro_prof_nsg_final.pdf

Grace, P.J. & Hardt E.J. (2008). Ethical issues: When a patient refuses assistance. American Journal of Nursing, 108 (8), 36-38. https://www.nursingcenter.com/journalarticle?Article_ID=807009&Journal_ID=54030&Issue_ID=806966

International Council of Nurses. (2012). The ICN code of ethics for nurses. https://www.icn.ch/sites/default/files/inline-files/2012_ICN_Codeofethicsfornurses_%20eng.pdf

Ludwick, R.S., & Silva, M.C. (2000). Ethics: Nursing around the world: Cultural values and ethical conflicts. Online Journal of Issues in Nursing, 5(3). https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Columns/Ethics/CulturalValuesandEthicalConflicts.aspx

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Reference:

National Cancer Institute. (n.d.). Advance Directives. MedlinePlus. Retrieved on September 24, 2021 from https://medlineplus.gov/advancedirectives.html

Royal College of Nursing. (2021, May 26). Refusal to treat. https://www.rcn.org.uk/get-help/rcn-advice/refusal-to-treat

Snyder, J.E., & Gauthier, C.C. (2008). Evidence-based medical ethics: Cases for practice-based learning. Humana Press. https://doi.org/10.1007/978-1-60327-246-9

Summers, J. (2014). Principles of healthcare ethics. In E.E. Morrison & B. Furlong (Eds.), Health care ethics: Critical issues for the 21st century (pp. 41-56). Jones & Bartlett Learning.

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