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Course: Pediatric Nursing

Topic: Ethical Issues in Child and Family Nursing

The Nurses International Community

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Module Goals

Learners will be able to:

Define the term “ethics.”
Identify the factors that influence ethics.
Discuss the core principles of health care ethics.
Discuss the various ethical issues in pediatrics.
Explain the nurses’ role during ethical dilemmas.

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Ethics

Derived from the Greek word “ethos,” which means “way of living”
Ethics is a branch of philosophy that is concerned with human conduct, more specifically, the behavior of individuals in society
Examines rational justification for one’s moral judgments
Studies what is morally right or wrong, just or unjust

Government of Canada, 2015

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Factors That Influence Ethics

Social Factors

Cultural norms
Religious beliefs
Ethical behavior of co-workers

Personal Factors

Level of emotional intelligence (personal skills such as empathy, honesty, self-management)
Stage of moral development
Gender, age, experience

Deshpande, 2009

Ferrell et al., 2015

Turner, 2001

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Factors That Influence Ethics (Continued)

Environmental/Organizational Factors

Ethical climate (strong ethics versus questionable norms)
Workload
Conflicting roles
Financial gain and political connections
Lack of oversight
Fear of retribution
Disaster situations

Abbasi et al., 2017

Deshpande, 2009

DuBois, 2012

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Core Principles of Healthcare Ethics

Four basic principles of ethics that apply to healthcare practices

Autonomy - Individual’s right to make their own decisions
Nonmaleficence - To do no harm
Beneficence - Acting for the good or benefit of others
Justice - Fairness and equal treatment of all individuals

Beauchamp & Childress, 2019

Olejarczyk & Young, 2022

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Autonomy

Self-determination
Requires two conditions:

An individual must be competent to make decisions for themselves.
An individual must be free of coercion in making decisions. (Informed consent is an example.)

Beauchamp & Childress, 2019

Olejarczyk & Young, 2022

Summers, 2014

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Non-Maleficence

In order to “do no harm,” one has to determine what constitutes “harm.”
In healthcare, harm is generally considered anything that worsens the client’s condition.
Interventions often involve both harm and good, usually described as risks and benefits.
Despite the potential benefit of treatment, the therapy may have unintended harm.

Beauchamp & Childress, 2019

Olejarczyk & Young, 2022

Summers, 2014

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Beneficence

Beneficence involves acting with kindness, compassion, and understanding.
In medicine, beneficence also involves providing benefits to clients by promoting and protecting their wellbeing.
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.

Beauchamp & Childress, 2019

Olejarczyk & Young, 2022

Bester 2020

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Justice

Requires that all clients are treated fairly and equitably
Two main categories:

Procedural justice is concerned with whether fair procedures are in place and being followed.
Distributive justice is concerned with the distribution of resources.

Beauchamp & Childress, 2019

Olejarczyk & Young, 2022

Summer, 2014

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Nursing Ethics

Ethical principles in nursing are guided by a code of ethics or code of conduct:

Set by q country specific governing authority of nursing practice
Code of ethics/conduct is non-negotiable
Holds nurses accountable for upholding a set code of ethics
Consequences applicable if failure to uphold ethical principles

One of the most widely used codes of ethics is the International Council of Nurses (ICN)- The ICN Code of Ethics for Nurses (2021).

International Council of Nurses, 2021

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Critical Thinking Question

Does your country have a code of ethics for nurses?

If so, read through it and consider how it upholds the core principles of healthcare ethics discussed in the previous slides.

If your country does not have a code of ethics for nurses, read through The ICN Code of Ethics for Nurses and consider the same question.

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Ethical Dilemma and Moral Distress

An ethical dilemma occurs when one recognizes that a problem exists and that two or more ethically justifiable but mutually opposing actions can be taken.

Moral distress occurs when one is constrained from taking an action that they believe to be the right one.

Epstein & Delgado, 2010

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Ethical Issues and Moral Distress in Pediatrics

Autonomy: Parents/guardians may have the authority to make decisions for the child.

Results in moral distress when:

The family disagrees with the care proposed by healthcare professionals.
Conflicts between divorced parents affect the child’s care.
End-of-life care: Accepting the family’s wishes to continue or withhold life support contrasts with what health care professionals believe to be the best.

Santos, Garros, & Carnevale, 2018

Hilton, 2019

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Ethical Issues and Moral Distress in Pediatrics

Conflict involving autonomy of parents and adolescents:

Disagreement between the parent and adolescent regarding adolescent care

Moral distress: How can healthcare professionals be respectful of both decisions?

Adolescents wishing to withhold information from parents

Moral distress: Inform the parents who are responsible for their child, Or maintain a relationship of trust and honesty with the client.

Santos, Garros, & Carnevaa le, 2018

Hilton, 2019

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Ethical Issues and Moral Distress in Pediatrics

Beneficence, non-maleficence, and justice:

Healthcare professionals’ duty to provide care that is fair, beneficial, and causes no harm is challenged by socioeconomic inadequacies and disparities.

Results in moral distress when:

Healthcare settings lack resources to manage child illnesses.
Children of poor economic status have less access to adequate health treatment and services.

Santos, Garros, & Carnevale, 2018

Hilton, 2019

Guedert & Grosseman, 2012

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Ethical Issues and Moral Distress in Pediatrics

Beneficence and Non-maleficence:

Child abuse and neglect should be addressed appropriately for the prevention or mitigation of physical and mental development problems in the child.

Discrepancies in the healthcare system related to the reporting of and interventions on child abuse/neglect.
Reporting to authorities may risk damaging the relationship of trust with children and/or parent.

Pediatric clinical trials must pass rigorous ethical evaluations.

Hilton, 2019

Guedert & Grosseman, 2012

Forsner et al., 2021

World Health Organization, n.d.

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Ethical Issues and Moral Distress in Pediatrics

Organizational limitations/constraints:

Lack of "blameless" environment results in health professionals hiding errors by self or others.
Lack of inclusion of nurses in the decision-making of the child's care undermines their:

Role as a client advocate
Potential contribution to better childcare

Lack of consensus on treatments leading to disagreements between the team members.

Santos, Garros, & Carnevale, 2018

Guedert & Grosseman, 2012

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Critical Thinking Question

The ethical principle of autonomy states that in pediatric cases, parents have the authority to make medical decisions for their children. However, sometimes parents make decisions about their child’s care that pose a danger to the child’s health (for example, choosing to withhold blood transfusions for religious reasons).

When the child’s welfare is at risk, do medical providers have an obligation to uphold the parents’ decision?

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In order to answer this question, the student should first look up whether there are any laws related to this issue in their country. In general, when the patient is a child (minor), their welfare comes first. In the case of a blood transfusion, what is best for the child is usually fairly obvious. However, things can become difficult when what is in the best interest of the child is not clear. As such, nurses and other medical professionals should rely on their country-specific laws related to medical decision-making in minors, rulings in their country related to similar cases, and local codes of ethics for their profession (international codes of ethics if none exist). If their place of practice has it, an ethics committee can be a tremendous resource and guide in pediatric cases with ethical concerns.

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Nurses’ Role During Ethical Dilemmas

Be cognizant of the national/state code of ethics for nurses.
Be knowledgeable of ethical-decision making models that guide decision-making.
Be agents of moral courage.

Moral courage is defined as "an individual's ability to overcome fear and to fight for the values in which he or she believes, which he or she considers fundamental."

Santos, Garros, & Carnevale, 2018

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Nurses’ Role During Ethical Dilemmas (Continued)

Know the agency’s protocols for ethical decision-making.

Advocate for organizational support and resources to help healthcare professionals:

Make appropriate decisions on complex ethical issues or dilemmas.
Prevent fatigue and demotivation from moral distress.

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Critical Thinking Question

An infant with a terminal illness is admitted to the hospital for respiratory support. Some members of the infant’s medical team feel that providing temporarily life-sustaining, but ultimately futile care versus comfort care is prolonging the infant’s suffering and is, therefore, unethical.

Other members of the team feel that everything possible should be done to prolong the infant’s life and that doing anything less would be unethical. Research various ethical-decision making models and then use one to determine how this situation could be addressed and resolved.

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Red Flags

Nurses who work in areas where there is increased moral distress are at risk for “burnout.”

(Best-Brandt, 2019)

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures, talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures, family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting and following treatment recommendations.

(AHRQ, 2020)

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health-seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be acceptable in some cultures but inappropriate or offensive in others.

(AHRQ, 2020)

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References:

Abbasi, M., Fadavi, M., & Bazmi, S. (2017). The underlying factors affecting ethical performance of health service providers when faced with disaster: A qualitative study. Journal of Medical Ethics and History of Medicine, 10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6150919/pdf/JMEHM-10-14.pdf

Attard-Montalto S. (2001). Ethical issues in paediatric practice - part I: general principles. Images in paediatric cardiology, 3(4), 1–3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3232508/

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

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References:

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

Deshpande, S.P. (2009). A study of ethical decision making by physicians and nurses in hospitals. Journal of Business Ethics, 90(3), 387-397. https://doi.org/10.1007/s10551-009-0049-5

DuBois, J.M., Carroll, K., Gibb, T., Kraus, E., Rubbelke, T., Vashner, M., & Anderson, E.E. (2012). Environmental factors contributing to wrongdoing in medicine: A criterion-based review of studies and cases. Ethics & Behavior, 22(3), 163-188. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3515073/

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References:

Epstein, E.G., & Delgado, S. (2010). Understanding and Addressing Moral Distress. The Online Journal of Issues in Nursing, 15(3). https://ojin.nursingworld.org/MainMenuCategories/EthicsStandards/Resources/Courage-and-Distress/Understanding-Moral-Distress.html

Ferrell, O.C, Fraedrich, J, & Ferrell, L. (2015). Business ethics: Ethical decision making and cases (10th ed.). Cengage Learning.

Forsner, M., Elvhage, G., Ewalds-Kvist, B.M. et al. (2021). Moral Challenges When Suspecting Abuse and Neglect in School Children: A Mixed Method Study. Child Adolesc Soc Work J,38, 599–610. https://doi.org/10.1007/s10560-020-00680-6

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References:

Government of Canada. (2015, July 3). What is ethics?. https://www.canada.ca/en/treasury-board-secretariat/services/values-ethics/code/what-is-ethics.html

Guedert, J.M., & Grosseman, S. (2012). Ethical problems in pediatrics: what does the setting of care and education show us?. BMC Med Ethics,13 (2). https://doi.org/10.1186/1472-6939-13-2

Hilton, L. (2019, April 1). Doctors share ethical issues that worry them most. Contemporary Pediatrics Journal, 36 (4). https://www.contemporarypediatrics.com/view/doctors-share-ethical-issues-worry-them-most

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References:

International Council of Nurses. (2021). The ICN code of ethics for nurses. https://www.icn.ch/system/files/2021-10/ICN_Code-of-Ethics_EN_Web_0.pdf

Olejarczyk, J.P., & Young, M. (2022, May 5). Patient Rights And Ethics. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538279/

Santos, R., Garros, D., & Carnevale, F. (2018). Difficult decisions in pediatric practice and moral distress in the intensive care unit. As difíceis decisões na prática pediátrica e sofrimento moral em unidade de terapia intensiva. Revista Brasileira de terapia intensiva, 30(2), 226–232. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6031410/

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References:

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.

Turner, L. (2001). Medical ethics in a multicultural society. Journal of the Royal Society of Medicine, 94, 592-594. https://journals.sagepub.com/doi/pdf/10.1177/014107680109401114

World Health Organization. (n.d.). Clinical trials in children. https://www.who.int/clinical-trials-registry-platform/clinical-trials-in-children

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