ETHICAL AND BIOETHICAL ISSUES
Ethical and bioethical Issues in Nursing and Health Care
In a nursing education program, educators can only begin to introduce the nursing student to the complex and dynamic profession of nursing. Prelicensure nursing education is only an introduction to a discipline in which there are no knowledge boundaries. The abundance of nursing practice information is clear from a quick glance across the nursing textbook shelves in the college bookstore.
Most of that information addresses the "how to" aspects of nursing care. The scientific aspects of nursing care are evolving more rapidly than ever as a host of nurse researchers delve into questions about the safe, competent, and therapeutic aspects of professional nursing care. As quickly as nursing science produces new nursing knowledge, "how to" information is shared through professional journals, textbooks, and electronically through on-line Internet resources. The scientific aspects of care for someone like the elderly woman described in the opening vignette are evolving constantly through "how to" research.
A myriad of potential questions that surpass the "how to" body of knowledge are inherent in the patient care situation presented in the vignette. Everywhere in today's health care delivery system are potential questions of another nature — the "how should" questions. "How should" questions sound something like this.
• How should I determine the competency of my acutely ill 80-year-old patient? Is her competency intact? How should I gain her informed consent?
• How should I act if it is determined that her wishes for aggressive care are not consistent with those of her family?
• How should I view her care? Is a resuscitation effort for an 80-year-old considered ordinary and routine, or is it considered extraordinary and heroic?
• How should I respond to her in the middle of the night when she awakens to ask me if she is dying?
• How much of the truth is warranted?
• How should I decide when the availability of ICU beds becomes threatened and the decision must be made to move someone out of ICU to make room for a new trauma patient?
• How should I make staffing assignments when the number of nurses on a given shift is insufficient to provide routine ICU care to all?
• Is the life of this 80-year-old woman any less significant than that of the 40-year-old father-of-four executive who has just been admitted after a tragic car accident?
• How should I feel when this 80-year-old patient is entered into a research study designed to test a new beta-blocker that has previously only been tested on a middle-age population?
This chapter introduces the nursing student to a different aspect of nursing care, this "how should" aspect or, as it is more appropriately called, the ethical aspect. Ethics is a system for deciding, based on principles, what should be done. Socrates once said, "The unexamined life is not worth living." Ethics is about examining life in a way that will add a dimension to the understanding that goes beyond the scientific and moves toward a more complete and whole understanding of human existence.
Nursing ethics is a system of principles concerning the actions of the nurse in his or her relationships with patients, patients' family members, other health care providers, policy makers, and society as a whole. A profession is characterized by its relationship to society. Codes of ethics provide implicit standards and values for the professions. A nursing code of ethics was first intro duced in the late nineteenth century and has evolved through the years as the profession itself has evolved and as changes in society and health have come about. Current dynamics such as emerging genetic interventions and new threats to the effective delivery of health care such as managed care and impending nursing shortages bring nursing's code of ethics into the forefront.
Nursing ethics is a part of a broader system known as bioethics. Bioethics is an interdisciplinary field within the health care organization that has developed only in the past three decades. Bioethics can be differentiated from ethics as ethics has been discussed in the written word since there was written word, whereas bioethics has developed with the age of modern medicine. New questions surface as new science and technology produce new ways of knowing. Bioethics is a response to contemporary advances in health care.
Dilemmas for Health Professionals
Physicians, nurses, social workers, psychiatrists, clergy, philosophers, theologians, and policy makers axe joining to address ethical questions, difficult questions, and right vs. wrong questions. As they seek to deliver quality health care, these professionals debate situations that pose dilemmas. They are confronting situations for which there are no clear right or wrong answers. Because of the diverse society in which health care is practiced, there are at least two sides to almost every issue faced.
Every specialization in health care has its own set of questions. Life and death, quality of life, right to decide, informed consent, and alternative treatment issues prevail in every field of health care from maternal-child to geriatric care, from acute episodic to intensive, highly specialized care, and from hospital-based to community-based care. In every aspect of the nursing profession lie the more subtle and intricate questions of "how should" this care be delivered and "how should" one decide when choices are in conflict.
Many nursing students do not consider health care and the practice of nursing in terms of the personal and subjective side; rather they look at it only in terms of the technical and objective side. Yet there most definitely are factors that influence the way patients actually are treated, or at least the way they perceive their treatment, that go beyond the technical aspect. In many ways technology has changed the face of health care and created the troubling questions that have become central in the delivery of care.
Dilemmas Created by Technology
Advances in health care through technology have created new situations for health care professionals and their patients. For the very young and old and for generations in between, illnesses once leading to mortality have now become manageable and are classified as high-risk or chronic illness. Although people can now be saved, they are not being saved readily or inexpensively. Care of the acutely or chronically ill person sometimes creates hard questions for which there are no easy or apparent answers. Mortality for most will be a long, drawn-out phenomenon, laced with a lifetime of potential conflicts about what ought to be done. Health care professionals who adhere to an exclusively scientific or technologic approach to care will be seen as insensitive and will fail to meet the genuine needs of the patient, needs that include assistance with these more subjective concerns.
ETHICAL DECISION MAKING
A professional nurse in the twenty-first century will be deemed competent only if he or she can provide the scientific and technologic aspects of care and has the ability to deal effectively with the ethical problems encountered in patient care. A competent nurse must be able to deal with the human dimensions of that care. The previously listed "how should" questions should be just as important as the "how to" questions surrounding the care of the 80-year-old patient introduced previously. As the nurse seeks to understand the "how to" aspects of the patient's care, such as comfort measures for dyspnea, pharmacologic care considering her organ dysfunction, and decubitus prevention in her immobile and malnourished state, he or she also must seek to understand more.
Answering Difficult Questions
Care combining human dimensions with scientific and technical dimensions forces some basic questions.
• What does it mean to be ill or well?
• What is the proper balance between science and technology and the good of humans?
• Where do we find balance when science will allow us to experiment with the basic origins of life?
• What happens when the proper balance is in tension?
No tension is created in the effort to save the life of a dying healthy adolescent or set the broken leg of a healthy elderly adult. Science and the human good are not in conflict here. However, what is the answer when modern medicine can save or prolong the life of an 8-year-old child but the child's parents refuse treatment based on religious reasons? Or what is the answer when modern medicine has life to offer a 30-year-old mother in need of a transplanted organ but the woman is without the financial means to cover the cost of the treatment? What is the answer when new discoveries allow some to even choose biologic characteristics of children not yet conceived? At one end of the spectrum lies the obvious; at the other there is often only uncertainty. Health care professionals in everyday practice often find themselves striving somewhere between the two.
Balancing Science and Morality
If nursing care is to be competent, the right balance between science and morality must be sought and understood. Nurses must first attempt to understand not just what they are to do for their patients but who their patients are. They must examine life and its origins, as well as its worth, usefulness, and importance. Nurses must determine their own values and seek to understand the values of others.
Health care decisions are seldom made independently of other people. Decisions are made with the patient, the family, other nurses, and other health care providers. Nurses must make a deliberate effort to recognize their own values and learn to consider and respect the values of others.
The nurse has an obligation to present himself or herself to the patient as competent. The dependent patient enters into a mutual relationship with the nurse. This exchange places a patient who is vulnerable and wounded with a nurse who is educated, licensed, and knowledgeable. The patient expects nursing actions to be thorough since total caring is the defining characteristic of the patient-nurse relationship. The nurse promises to deliver holistic care to the best of his or her ability. The patient's expectations and the nurse's promises require a commitment to develop a reasoned thought process and sound judgment in all situations that take place within this important relationship. The more personal, subjective, and value-laden situations are deemed to be among the most difficult situations for which the nurse must prepare.
VALUES FORMATION AND MORAL DEVELOPMENT
A value is a personal belief about worth that acts as a standard to guide behavior; a value system is an entire framework on which actions are based. Diane Uustal, a well-known nurse ethicist, describes values as being a basis for what a person thinks about, chooses, feels for, and acts on (1992). Perhaps many nursing students come to the educational setting with an intact value system. No doubt anyone living in these times has faced many situations in which important choices had to be made. The options available to this generation are too numerous to avoid hard choices. Values have been applied to those decisions. Yet often people do not take time to seriously contemplate their value system, the forces that shaped those values, and the life and world-view decisions that have been made based on them.
Examining Value Systems
To become a competent professional in every dimension of nursing care, nurses must examine their own system of values and commit themselves to a virtuous value system. A clear understanding of what is right and wrong is a necessary first step to a process sometimes referred to as values clarification, a process by which people attempt to examine the values they hold and how each of those values functions as part of a whole. Nurses must acknowledge their own values by considering how they would act in a particular situation.
A values clarification process (Uustal, 1992) is an important learning tool as nursing students prepare themselves to become competent professionals. The deliberate refinement of one's own personal value system leads to a clearer lens through which nurses can view ethical questions in the practice of their profession. A refined value system and world view can serve professionals as they deal with the meaning of life and its many choices. A world view provides a cohesive model for life; it encourages personal responsibility for the living of that life, and it prepares one for making ethical choices encountered throughout life.
Forming a world view and a value system is an evolving, continuous, dynamic process that moves along a continuum of development often referred to as moral development. Just as there is an orderly sequence of physical and psychologic development, there is an orderly sequence of right and wrong conduct development. Consider an adult of mighty physical prowess and strong moral character. Just as with each biologic developmental milestone there is a more mature, more expanded physical being, with each life experience that has right and wrong choices there is a more mature, more virtuous person.
Learning Right and Wrong
The process of learning to distinguish right and wrong often is described in pediatric textbooks. Donna Wong describes such development in children (1999). Infants have no concept of right or wrong. Infants hold no beliefs and no convictions, although it is known that moral development begins in infancy. If the need for basic trust is met in infancy, children can begin to develop the foundation for secure moral thought. Toddlers begin to display behavior in response to the world around them. They will imitate behavior seen in others, even though they do not comprehend the meaning of the behavior that they are imitating. Further, even though toddlers may not know what they are doing or why they are doing it, they incorporate the values and beliefs of those around them into their own behavioral code.
By the time children reach school age, they have learned that behavior has consequences and that good behavior is associated with rewards and bad behavior is associated with punishment. Through their experiences and social interactions with people outside their home or immediate surroundings, school-age children begin to make choices about how they will act based on an understanding of good and bad. Their conscience is developing, and it begins to govern those choices they make (Wong, 1999).
The adolescent questions existing moral values and his or her relevance to society. Adolescents understand duty and obligation, but they sometimes seriously question the moral codes on which society operates as they become more aware of the contradictions they see in the value systems of adults.
Adults strive to make sense of the contradictions and learn to develop their own set of morals and values as autonomous people. They begin to make choices based on an internalized set of principles that provides them with the resources they need to evaluate situations in which they find themselves (Wong et al., 1999).
Understanding Moral Development Theory
Perhaps the most widely accepted theory on moral development is Lawrence Kohlberg's theory (1971). Kohlberg theorizes a cognitive developmental process that is sequential in nature with progression through levels and stages, which vary dramatically within society. At first morality is all about rules imposed by some source of authority. Moral decisions made at this level (preconventional) are simply in response to some threat of punishment. The good-bad, right-wrong labels have meaning but are defined only in reference to a self-centered reward and punishment system. A person who is in the preconventional level has no concept of the underlying moral code informing the decision of good-bad or right-wrong.
At some point people begin to internalize their view of themselves in response to something more meaningful and interpersonal (conventional level). A desire to be viewed as a good boy or nice girl develops when the person wants to find approval from others. He or she may want to please, help others, be dutiful, and show respect for authority. Conformity to expected social and religious mores and a sense of loyalty may emerge.
Not all people develop beyond the conventional level of moral development. A morally mature individual (postconventional level), one of the few to reach moral completeness, is an autonomous thinker who strives for a moral code beyond issues of authority and reverence. The morally mature individual's actions are based on principles of justice and respect for the dignity of all humankind and not just on principles of responsibility, duty, or self-edification (Kohlberg, 1971).
Moving Toward Moral Maturity
The Tightness or wrongness of the complex and confounding health care decisions that are being made today depends on the level of moral development of those professionals entrusted with the tough decisions. Moving toward the level of moral maturity required for such decision making is, for most, a learning endeavor that requires a strong commitment to the task. Nurses must commit themselves to such learning.
The American Association of Colleges of Nursing (AACN) provides the profession with the results of a study in which the essential knowledge, skilled practice, and values necessary for nursing were delineated. From a consensus-building effort across the nation, the AACN has recommended seven values that are essential for the professional nurse.
The study and examination of these nursing values is a worthwhile endeavor for the nursing student. Students who seek to become morally mature health care providers will appraise the values of the nursing profession and strive to find a comfortable union of those values with their own. Further, the study of ethical theory and ethical principles can provide a basis for moving forward as a morally mature professional nurse.
Ethical theory is a system of principles by which a person can determine what ought and ought not to be done. Although there are others, utilitarianism and deontology are theories that encompass modern moral thought and provide approaches for answering the question regarding what is right to do in a given ethical dilemma (Davis et al., 1997).
Utilitarianism is an approach that is rooted in the assumption that an action or practice is right if it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences. Utilitarian ethics are noted to be the strongest approach used in bioethical decision making. An attempt is made to determine which actions will lead to the greatest ratio of benefit to harm for all persons involved in the dilemma.
Deontology is an approach that is rooted in the assumption that humans are rational and act out of principles that are consistent and objective and that compel them to do what is right. Ethics are based on a sense of universal principle to consistently act one way. In bioethical decision making, moral Tightness is the act that is determined not by the consequences it produces, but by the moral qualities intrinsic to the act itself. Deontologic theory claims that a decision is right only if it conforms to an overriding moral duty and wrong only if it violates that moral duty. All decisions must be made in such a way that the decision could become universal law. Persons are to be treated as ends in themselves and never as means to the ends of others.
Perhaps the most useful tool for the morally mature professional nurse is a set of principles, standards, or truths on which to base ethical actions. Common ground must be established between the nurse and the patient and the family, between fellow nurses, between the nurse and other health care providers, and between the nurse and other members of society. A set of mutually agreed on principles makes it possible for people to come together to discuss ethical questions and move toward a sense of understanding and agreement (Husted and Husted, 1995).
The practice of ethics involves applying principles to the two ethical theories described, utilitarianism and deontology, or to other theories that are described elsewhere. Principles can permit people to take a consistent position on specific or related issues. If the principles, when applied to a particular act, make the act right or wrong in one situation, it seems reasonable to assume that the same principle, when applied to a new situation, can share similar features. Three principles have proven to be highly relevant in bioethics: (1) autonomy, (2) beneficence, nonmaleficence, and (3) veracity.
These principles are not related in such a way that they jointly form a complete moral framework. One may be relevant to a situation, whereas the others are not. Yet these principles are sufficiently comprehensive to provide an analytic framework by which moral problems can be evaluated.
Autonomy, the principle of respect for the person, or the principle of autonomy, is sometimes labeled as the primary moral principle. The umbrella concept says that humans have incalculable worth or moral dignity not possessed by other objects or creatures. There is unconditional intrinsic value for all persons. People are free to form their own judgments and whatever actions they choose. They are self-determining agents, entitled to determine their own destiny.
If an autonomous person's actions do not infringe on the autonomous actions of others, that person should be free to decide however he or she wishes. This freedom should be applied even if the decision creates risk to his or her health and even if the decision seems unwise to others. Concepts of freedom and informed consent are grounded in the principle of autonomy.
In general terms, to be beneficent is to promote goodness, kindness, and charity. On the other end of the spectrum from the beneficence principle is nonmaleficence, a principle that implies a duty not to inflict harm. In ethical terms nonmaleficence is to abstain from injuring others and to help others further their own well-being by removing harm and eliminating threats, whereas beneficence is to provide benefits to others by promoting their good. The beneficence-nonmaleficence principle is largely a balance of risk and benefit. At times the risk of harm must be weighed against possible benefits. The risk should never be greater than the importance of the problem to be solved.
Although it may seem natural to promote good at all times, the most common bioethical conflicts result from an imbalance between the demands of beneficence and those acts and decisions within the health care delivery system that might pose threats. For instance, it is not always clearly evident what is good and what is harmful. Is the resuscitation effort of the 80-year-old woman good or harmful to her overall sense of well-being? How much beneficence is there in supporting someone toward a peaceful death?
Most contemporary professionals believe that telling the truth in personal communication is a moral and ethical requirement. If there is the belief in health care that truth-telling is always characteristic of right, then the principle of veracity can itself pose some interesting challenges.
In the past, truth-telling was sometimes viewed as inconvenient, distressing, or even harmful to patients and families. The first American Medical Association Code of Ethics in 1847 contained such a message:
The life of a sick person can be shortened not only by the acts, but also by the words or the manner of a physician. It is, therefore, a sacred duty to guard himself carefully in this respect, and to avoid all things that have a tendency to discourage the patient and to depress his spirits.
The belief that the truth could at times be harmful was held for many years. Only recently with the shift from a provider-driven system to a consumer-driven system has the history of silence begun to break. With this shift have come interesting questions. Is the provider-patient relationship generally understood by both parties to include the right of the provider to control the truth by withholding some or all of the relevant information until an appropriate time for disclosure? How much deception with patients is morally acceptable in the communication of a poor or terminal prognosis?
Difficult questions surface, but at the heart of the principle of veracity is trust. Health care consumers today expect accurate and precise information that is revealed in an honest and respectful manner. A few generations ago the trust factor may have been such that it was acceptable for providers to share parts of truth or to distort the truth in the name of beneficence. Today, however, for trust to develop between providers and patients, there must be truthful interaction and meaningful communication. The moral conflict that results from being less than truthful to patients is too troublesome for today's practitioner. The deontologic theory of the health care provider having a duty to tell the patient the truth has taken precedence over the fear of harm that might result if the truth is revealed. The challenge today is to mesh together the need for truthful communication with the need to protect. Health care providers must lay aside fears that the truth will be harmful to patients and come to the realization that more often than not the truth can alleviate anxiety, increase pain tolerance, facilitate recovery, and enhance cooperation with treatment. With a pledge toward human decency, health care providers must commit themselves to truth-telling in all interactions and relationships.
ETHICAL DECISION-MAKING MODEL
Theories provide a cognitive plan for considering ethical issues; principles offer guiding truths on which to base ethical decisions. Using these theories and principles, it seems appropriate to consider a system for moving beyond a specific ethical dilemma toward a morally mature and reasoned ethical action.
Many ethical decision-making
models exist for the purpose of defining a process by which a nurse or another
health care provider actually can move through an ethical dilemma toward an
Situation Assessment Procedure
Identify the Ethical Issues and Problems, in the first step of assessment there is an attempt to find out the technical and scientific facts and the human dimension of the situation— the feelings, emotions, attitudes, and opinions. A nurse must make an attempt to understand what values are inherent in the situation. Finally, the nurse must deliberately state the nature of the ethical dilemma. This first step is important because the issues and problems to be addressed are often complex. Trying to understand the full picture of a situation is time consuming and requires examination from many different perspectives, but it is worth the time and effort to understand an issue fully before moving forward in the assessment procedure. Wright (1987) poses some important questions that must be addressed in this first step.
1. What is the issue here?
2. What are the hidden issues?
3. What exactly are the complexities of this situation?
4. Is anything being overlooked?
Select One Alternative. Multiple factors come together in the third step. After identifying the issues and analyzing all possible alternatives, the skillful decision maker steps back to consider the situation again. There is an attempt to reflect on ethical theory and to mesh that thinking with the identified ethical principles for each alternative. The decision maker's own value system is applied, along with an appraisal of the profession's values for the care of others. A reasoned and purposeful decision results from the blending of each of these factors.
Justify the Selection. The rational discourse on which the decision is based must be shared in an effort to justify the decision. The decision maker must be prepared to communicate his or her thoughts through an explanation of the reasoning process used. According to Wright (1987), the justification for a resolution to an ethical issue is an argument wherein relevant and sufficient reasons for the correctness of that resolution are presented. Defending an argument is not an easy task, but it is a necessary step to communicate the reasons or premises on which the decision is based. A systematic and logical argument will show why the particular resolution chosen is the correct one. This final step is important to advance ethical thought and to express sound judgment. Wright's formula for the justification process is as follows:
1. Specify reasons for the action.
2. Clearly present the ethical basis for these reasons.
3. Understand the shortcomings of the justification.
4. Anticipate objections to the justification.