Values, Ethics, and Advocacy
Questions of Values and Ethics
Not so long ago, we had neither the knowledge nor the technology to prolong life. The main role of nurses and physicians was to support patients through the time of illness, helping them toward recovery or keeping them comfortable until death. There were few “who shall live, and who shall die?’’ decisions.
In the late 1960s, technological advances made the intensive care unit possible. Health care can now keep alive people who would die without intervention. The development of new drugs and advances in biomechanical technology permit physicians and nurses to challenge nature. This progress also brings new, perplexing questions. The ability to prolong life has created some heartbreaking situations for families and terrible ethical dilemmas for healthcare professionals. How is the decision made about when it is time to turn off the life support machines that are keeping alive someone’s beloved son or daughter after, for example, an auto accident? Families and professionals alike are faced with some of the most difficult ethical decisions at times like this. How do we define death? How do we know when it has occurred? Perhaps we also need to ask, “What is life? Is there ever a time when life is no longer worth living?’’
Healthcare professionals have looked to philosophy, especially the branch that deals with human behavior, for resolution of these issues. The field of biomedical ethics (or simply bioethics), a subdiscipline of the area known as ethics—or the philosophical study of morality, has evolved. In essence, bioethics is the study of medical morality, the moral and social implications of health care and science in human life (Mappes & Zembaty, 1991).
To understand biomedical ethics, we need to first consider the basic concepts of values, belief systems, and morality. We will then discuss the resolution of ethical dilemmas in health care.
The dictionary defines values as the “estimated or appraised worth of something, or that quality of a thing that makes it more or less desirable, useful’’ (Webster’s New World Dictionary, 1990). Values, then, are judgments about the importance or unimportance of objects, ideas, attitudes, and attributes. They become a part of a person’s conscience and worldview. Values provide a frame of reference and act as pilots to guide behaviors and assist people in making choices.
A value system is a set of related values. For example, one person may value (believe to be important) material things, such as money, objects, and social status. Another person may value more abstract concepts, such as kindness, charity, and caring. Values may vary significantly based on an individual’s culture. One’s system of values frequently affects how people make decisions. For example, one person may base a decision on cost, and another person placed in the same situation may base the decision on kindness. There are different kinds of values:
• Intrinsic values are those related to sustaining life, such as food and water (Steele & Harmon, 1983).
• Extrinsic values are not essential to life. Things, people, and ideas such as kindness, understanding, and material items are extrinsically valuable.
• Personal values are qualities that people consider valuable in their private lives. Such things as strong family ties and acceptance by others are personal values.
• Professional values are qualities considered important by a professional group. Autonomy, integrity, and commitment are examples of professional values.
People’s behavior is motivated by values. Individuals take risks, relinquish their own comfort and security, and generate extraordinary efforts because of their values (Edge & Groves, 1994). Stroke patients may overcome tremendous barriers because they value independence. Racecar drivers may risk death or other serious injury because they value competition and winning.
Values are also the basis of standards by which people judge others. For example, if you value work over leisure activities, you will look unfavorably on the coworker who refuses to work over the weekend. If you believe that health is more important than wealth, you would approve of spending money on a relaxing vacation or perhaps joining a health club, rather than putting it in the bank. Often people adopt the values of individuals they admire. For example, a nursing student may begin to value humor after observing it used effectively with clients. You can see that values provide a guide for decision making and give additional meaning to life. Individuals develop a sense of satisfaction when they work toward achieving values they believe are important.
How Values are Developed
Values are learned (Wright, 1987). Values can be taught directly, incorporated through societal norms, or modeled through behavior. Children learn by watching their parents, friends, teachers, and religious leaders. Through continuous reinforcement, children eventually learn about and then adopt values as their own. Because of the values they hold dear, people often make great demands on themselves, ignoring the personal cost. Here is an example:
David grew up in a family in which educational achievement was highly valued. Not surprisingly, he adopted this as one of his own values. At school, he worked very hard because some of the subjects did not come easily to him. When his grades did not reflect his great effort, he felt as though he had disappointed his family as well as himself. By the time David reached the age of 15, he had developed severe migraine headaches.
Values change with experience and maturity. For example, young children often value objects, such as a favorite blanket or stuffed animal. Older children are more likely to value a particular event, such as a scouting expedition. As they enter adolescence, they may value peer opinion over the opinions of their parents. Young adults often value certain ideals, such as beauty and heroism. The values of adults are formed from all of these experiences as well as from learning and thought. The number of values that people hold is not as important as what values they consider to be important. Choices are influenced by values. The way people use their own time and money, choose friends, and pursue a career are all influenced by values.
Values clarification is deciding what you believe is important. It is the process that helps people become aware of their own values. Values play an important role in everyday decision making. For this reason, nurses need to be aware of what they value and what they do not. This process helps them to behave in a manner that is consistent with their values. Both personal and professional values can affect nurses’ decisions. Understanding your values simplifies solving problems, making decisions, and developing better relationships with others when you begin to realize how they develop their values. Raths, Harmon, and Simmons (1979) suggested using a threestep model of choosing, prizing, and acting, with seven substeps, to identify your own value.
You may have used this method when making the decision to return to school. Today, many career options are available to men and women. For some people, nursing is a first career; for others, it may be a second career. Using the model in Table 13–1, let’s analyze the valuing process:
1. Choosing. After researching alternative career options, you freely chose nursing school from a whole range of options. This choice was most likely influenced by factors such as educational achievement and abilities, finances, support and encouragement from others, time factors, and feelings about people.
2. Prizing. Once the choice was made, you were satisfied with it and told your friends about it.
3. Acting. You have entered school and begun the journey to your new career. Later in your career, you may decide to return to school for a bachelor’s or master’s degree.
As you have progressed through school, you have probably begun to develop a new set of values—your professional values. Professional values are those established as being important in your practice, such as caring, quality of care, and ethical behaviors.
Belief systems are an organized way of thinking about why people exist within the universe. The purpose of belief systems is to explain such mysteries as life and death, good and evil, and health and illness. Usually these systems include an ethical code that specifies appropriate behavior. People may have a personal belief system or participate in a religion that provides such a system, or both.
Members of primitive societies worshiped events in nature. Unable to understand the science of weather, for example, early civilizations believed these things to be under the control of someone or something that needed to be appeased, and they developed rituals and ceremonies to appease these unknown entities. In doing this, they named these entities gods, believing that certain behaviors either pleased or angered the gods. Because these societies associated certain behaviors with specific outcomes, they created a belief system that enabled them to function as a group.
As higher civilizations evolved, belief systems became more complex. Archeology has provided us with evidence of the religious practices of ancient civilizations (Wack, 1992). The Aztec, Mayan, Incan, and Polynesian cultures each had a religious belief system comprising many gods and goddesses for the same functions. The Greek, Roman, Egyptian, and Scandinavian societies believed in a hierarchy of gods as well as individual gods and goddesses. Interestingly, although given different names by different cultures, most of the deities had similar purposes. For example, Zeus was the Greek king of the gods, and Thor was the Norse god of thunder. Both used a thunderbolt as their symbol. Sociologists believe that these religions developed to explain what was then unexplainable. Human beings have a deep need to create order from chaos and to have logical explanations regarding events. Religion explains theologically what objective science cannot.
Along with the creation of rites and rituals, religions also developed codes of behaviors, or ethical codes. These codes contribute to the social order. There are rules regarding how to treat members of the family, neighbors, the young, and the old. Many religions have also developed rules regarding marriage, sexual practices, business practices, the ownership of property, and rules of inheritance.
The advancement of science certainly has not made belief systems any less important. In fact, the technology explosion has created an even greater need for these systems. Technological advances often place people in situations that justify religious convictions rather than oppose them. Many religions, and particularly Christianity, focus on the will of a supreme being, and technology, for example, is considered a gift that allows healthcare personnel to maintain the life of a loved one. Other religions, such as certain branches of Judaism, focus on free choice or free will, leaving such decisions in the hands of humankind. Genetic testing is an example of this approach. Many religious leaders believe that if genetic testing indicates, for instance, that an infant will be born with a disease such as Tay-Sachs, which causes severe suffering and ultimately death, an abortion may be an acceptable option.
Belief systems often help survivors in making decisions and living with them afterward. So far, more questions than answers have emerged from these technological advances. As science explains more and more previously unexplainable phenomena, we need beliefs and values to guide our use of this new knowledge.
ETHICS AND MORALS
Although the terms morals and ethics are often used interchangeably, ethics usually refers to a standardized code as a guide to behaviors, whereas morals usually refers to an individual’s own code for acceptable behavior. Morals arise from an individual’s conscience. They act as a guide for individual behavior and are learned through instruction and socialization. You may find, for example, that you and your clients disagree on the acceptability of certain behaviors, such as premarital sex, taking drugs, or gambling. Even in your nursing class, you will probably encounter some disagreements because each of you has developed a personal code that defines acceptable behavior.
Ethics is the part of philosophy that deals with the rightness or wrongness of human behavior. It is also concerned with the motives behind behaviors. Bioethics, specifically, is the application of ethics to issues that pertain to life and death. The implication is that judgments can be made about the rightness or goodness of healthcare practices.
Ethical codes are based on principles that can be used to judge behavior. Ethical principles assist decision making because they are a standard for measuring actions. They may be the basis for laws, but they themselves are not laws. Laws are rules created by a governing body. Laws can operate because the government has the power to enforce them. They are usually quite specific, as are the punishments for disobeying them. Ethical principles are not confined to specific behaviors. They act as guides for appropriate behaviors. They also take into account the situation in which a decision must be made. You might say that ethical principles speak to the essence or fundamentals of the law, rather than to the exactness of the law (Macklin, 1987). Here is an example:
Mrs. Van Gruen, 82 years old, was admitted to the hospital in acute respiratory distress. She was diagnosed with aspiration pneumonia and soon became septic, developing adult respiratory distress syndrome (ARDS). She had a living will, and her attorney was her designated healthcare surrogate. Her competence to make decisions was uncertain because of her illness. The physician presented the situation to the attorney, indicating that without a feeding tube and tracheostomy, Mrs. Van Gruen would die. According to the laws governing living wills and healthcare surrogates, the attorney could have made the decision to withhold all treatments. However, he felt he had an ethical obligation to still discuss the situation with his client. The client requested hat the tracheostomy and the feeding tube be inserted, which was done.
In some situations, two or more principles may conflict with each other. Making a decision under these circumstances is very difficult. We now consider several of the ethical principles that are most important to nursing practice—autonomy, nonmaleficence, beneficence, justice, confidentiality, veracity, and accountability — and then look at some of the ethical dilemmas nurses encounter in clinical practice.
Autonomy is the freedom to make decisions for oneself. This ethical principle requires that nurses respect clients’ rights to make their own choices about treatment. Informed consent before treatment, surgery, or participation in research is an example. To be able to make an autonomous choice, individuals need to be informed of the purpose, benefits, and risks of the procedures to which they are agreeing. Nurses accomplish this by providing information and supporting clients’ choices.
Nurses are often in a position to protect a client’s autonomy. They do this by ensuring that others do not interfere with the client’s right to proceed with a decision. If a nurse observes that a client has insufficient information to make an appropriate choice, is being forced into a decision, or is unable to understand the consequences of the choice, then the nurse may act as a client advocate to ensure the principle of autonomy.
Sometimes nurses have difficulty with the principle of autonomy because it also requires respecting another’s choice even if you disagree with it. According to the principle of autonomy, a nurse cannot replace a client’s decision with his or her own, even when the nurse honestly believes that the client has made the wrong choice. A nurse can, however, discuss concerns with clients and make sure they have thought about the consequences of the decision they are about to make.
The ethical principle of nonmaleficence requires that no harm be done, either deliberately or unintentionally. This rather complicated word comes from Latin roots:
non = not
male = bad
facere = to do
The principle of nonmaleficence also requires that nurses protect from danger individuals who are unable to protect themselves because of their physical or mental condition. An infant, a person under anesthesia, and a person with Alzheimer’s disease are examples of people with limited ability to protect themselves. We are ethically obligated to protect our clients when they are unable to protect themselves.
This obligation to do no harm extends to the nurse who for some reason is not functioning at an optimal level. For example, a nurse who is impaired by alcohol or drugs is knowingly placing clients at risk. Other nurses who observe such behavior have an ethical obligation to protect the client according to the principle of nonmaleficence.
The word beneficence also comes from Latin roots:
bene = well
facere = to do
The principle of beneficence demands that good be done for the benefit of others. For nurses, this is more than delivering competent physical or technical care. It requires helping clients meet all their needs, whether physical, social, or emotional. Beneficence is caring in the truest sense, and caring fuses thought, feeling, and action—knowing and being truly understanding of the situation and the thoughts and ideas of the individual (Benner & Wrubel, 1989).
Sometimes physicians, nurses, and families withhold information from clients for the sake of beneficence. The problem with doing this is that it does not allow competent individuals to make their own decisions based on all available information. In an attempt to be beneficent, the principle of autonomy is violated. This is just one of many examples of the ethical dilemmas encountered in nursing practice. For instance:
Mrs. Gonzalez has just been admitted to the oncology unit with ovarian cancer. She is scheduled to begin chemotherapy treatment. Her two children and her husband have requested that the physician ensure that Mrs. Gonzalez not be told her diagnosis because they feel she would not be able to deal with it. The information is communicated to the nursing staff.
After the first treatment, Mrs. Gonzalez becomes very ill. She refuses the next treatment, stating that she didn’t feel sick until she came to the hospital. She asks the nurse what could possibly be wrong with her that she needs a medicine that makes her sick when she doesn’t feel sick. Only people who get cancer medicine get this sick! Mrs. Gonzalez then asks the nurse, “Do I have cancer?’’
As the nurse, you understand the order that the client is not to be told her diagnosis. You also understand your role as a patient advocate.
1. To whom do you owe your duty—the family or the client?
2. How do you think you may be able to be a client advocate in this situation?
3. What information would you communicate to the family, and how can you assist them in dealing with their mother’s concerns?
The principle of justice obliges nurses and other healthcare professionals to treat every person equally regardless of gender, sexual orientation, religion, ethnicity, disease, or social standing (Edge & Groves, 1994). This principle also applies in the work and educational setting. Everyone should be treated and judged by the same criteria according to this principle. Here is an example:
Found on the street by the police, Mr. Johnson was admitted through the emergency room to a medical unit. He was in deplorable condition, wearing dirty, ragged clothes, unshaven, and covered with blood. His diagnosis was chronic alcoholism, complicated by esophageal varices and end-stage liver disease. Several nursing students overheard the staff discussing Mr. Johnson. The essence of the conversation was that no one wanted to care for him because he was dirty, smelly, and brought this condition on himself. The students, upset by what they heard, went to their instructor about the situation. The instructor explained that every individual has a right to good care despite his or her economic or social position. This is the principle of justice.
The principle of confidentiality states that anything said to nurses and other healthcare providers by their clients must be held in the strictest confidence. Exceptions exist only when clients give permission for the release of information or when the law requires the release of specific information. Sometimes, just sharing information without revealing an individual’s name can be a breach in confidentiality because the situation and the individual are identifiable. It is important to realize that what seems like a harmless statement can become harmful if other people can piece together bits of information and identify the client.
Nurses come into contact with people from different walks of life. When working within communities, people are bound to know people, who know other people, and so on. Individuals have lost families, jobs, and insurance coverage because nurses have shared confidential information and others have acted on that knowledge (AIDS Update Conference, 1995).
In today’s electronic environment the principle of confidentiality has become a major concern. Many healthcare institutions, insurance companies, and businesses use electronic media to transfer information. These institutions store sensitive and confidential information in computer databases. These databases need to have security safeguards to prevent unauthorized access. Healthcare institutions have addressed the situation through the use of limited access, authorization passwords, and security tracking systems. It is important to remember that even the most secure system developed is vulnerable and can be accessed by an individual who understands the complexities of computer systems.
Veracity requires nurses to be truthful. Truth is fundamental to building a trusting relationship. Intentionally deceiving or misleading a client is a violation of this principle. Deliberately omitting a part of the truth is deception and violates the principle of veracity. This principle often creates ethical dilemmas. When is it all right to lie? Some ethicists believe it is never appropriate to deceive another individual. Others think that if another ethical principle overrides veracity, then lying is permissible. Consider this situation:
Ms. Allen has just been told that her father has Alzheimer’s disease. The nurse practitioner wants to come into the home to discuss treatment. Ms. Allen refuses, saying that the nurse practitioner should under no circumstances tell her father the diagnosis. She explains to the practitioner that she is sure he will kill himself if he learns that he has Alzheimer’s disease. She bases this concern on statements he has made regarding this disease.
The nurse practitioner replies that a medication is available that might help her father. However, it is available only through a research study being conducted at a nearby university. To participate in the research, the client must be informed of the purpose of the study, the medication to be given, its side effects, and followup procedures. Ms. Allen continues to refuse to allow her father to be told his diagnosis because she is positive he will commit suicide.
The nurse practitioner faces a dilemma: does he abide by Ms. Allen’s wishes based on the principle of beneficence, or does he abide by the principle of veracity and inform his client of the diagnosis. What would you do?
Accountability means accepting responsibility for one’s actions. Nurses are accountable to their clients and to their colleagues. When providing care to clients, nurses are responsible for their own actions, good and not so good. If something was not done, do not chart or tell a colleague that it was. An example of violating accountability is the story of Anna:
Anna was a registered nurse who worked nights on an acute care unit. She was an excellent nurse, but as the acuity of the clients’ conditions increased, she was unable to keep up with both clients’ needs and the technology, particularly IVs. She began to chart that all the IVs were infusing as they should, even when they were not. Each morning, the day shift would find that the actual infused amount did not agree with what the paperwork showed. One night, Anna allowed an entire liter to be infused into a client with congestive heart failure in 2 hours. When the day staff came on duty, they found the client expired, the bag empty, and the tubing filled with blood. Anna’s IV sheet showed 800 mL left in the bag. It was not until a lawsuit was filed that Anna took responsibility for her behavior. The idea of a standard of care evolves from this principle. Standards of care provide a ruler for measuring nursing actions.
A code of ethics is a formal statement of the rules of ethical behavior for a particular group of individuals. A code of ethics (see Chapter 16 and Appendix 1) is one of the hallmarks of a profession. This code makes clear the behavior expected of its members. The Nursing Code of Ethics provides values, standards, and principles to help nursing function as a profession.
Ethical codes are dynamic. They reflect the values of the profession and the society for which they were developed. Changes occur as society and technology evolve. For example, years ago no thought was ever given to do not resuscitate (DNR) orders or withholding food and fluids. These things were not issues then, but the technological advances that have made it possible to keep people in a kind of twilight life, comatose and unable to participate in living in any way, have made these very important issues in health care. It is not the purpose of ethical codes to change with every little breeze but to maintain a steady course, evolving as needed, but continuing to emphasize the basic ethical principles. Technology has increased our knowledge and skills, but our ability to make decisions regarding ourselves and those we care for is still guided by the principles of autonomy, maleficence, beneficence, justice, accountability, and veracity.
What is a dilemma? The word dilemma is of Greek derivation. A lemma was an animal resembling a ram and having two horns. Thus came the saying “stuck on the horns of a dilemma.” The story of Hugo illustrates a hypothetical life-or-death dilemma with a touch of humor:
One day, Hugo, dressed in a bright red cape, walked through his village into the countryside. The wind caught the corners of the cape, and it was being whipped in all directions. As he walked down the dusty road, Hugo happened to pass by a lemma. Hugo’s bright red cape caught the lemma’s attention.
Lowering its head with its two horns poised in attack position, the animal began to chase poor Hugo down the road. Panting and exhausted, Hugo reached the end of the road to find himself blocked by a huge stone wall. He turned to face the lemma, which was ready to charge. A decision needed to be made, and Hugo’s life depended on this decision. If he moved to the left, the lemma would gore his heart. If he moved to the right, the lemma would gore his liver. Alas, no matter what his decision, our friend Hugo would be “stuck on the horns of da lemma.’’
Like Hugo, nurses are often faced with difficult dilemmas. Also, as Hugo found, an ethical dilemma can be a choice between two unpleasant alternatives.
An ethical dilemma occurs when a problem exists that forces a choice between two or more ethical principles. Deciding in favor of one principle will violate the other. Both sides have goodness and badness to them, but neither decision satisfies all the criteria that apply. Ethical dilemmas also have the added burden of emotions. Feelings of anger, frustration, and fear often override rationality in the decision-making process. Consider the case of Mr. Sussman:
Mr. Sussman, 80 years old, was admitted to the neuroscience unit after suffering left hemispheric bleeding. He had total right hemiplegia and was completely nonresponsive, with a Glasgow Coma Scale score of 8. He had been on IV fluids for 4 days, and the question of placing a percutaneous endoscopic gastrostomy (PEG) tube for enteral feedings was raised. The elder of the two children asked what the chances of recovery were. The physician explained that Mr. Sussman’s current state was probably the best he could attain but that miracles happen every day and stated that tests could help in determining the prognosis. The family asked that these be performed.
After the results were in, the physician explained that the prognosis was grave, but that IV fluids were insufficient to sustain life. The PEG tube would be a necessity if the family wished to continue with food and fluids. As the physician went down the hall, the family pulled in the nurse, Gail, who had been with Mr. Sussman during the previous 3 days and asked, “If this were your father, what would you do?’’ This situation became an ethical dilemma for Gail as well. If you were Gail, what would you say? Depending on your answer, what would be the possible principles that you might violate?