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TOPIC 9. ETHICAL ASPECTS OF NURSING
9.1. INTRODUCTION NURSING CODE OF CONDUCT
A code of ethics is a formal statement of a group’s ideals and values. It is a set of ethical principles that is shared by members of the group, reflects moral judgments over time, and serves as a standard for their professional actions.
LEARNING OUTCOMES
At the end of this lecture, students will be able to :
- Define nursing codes of ethics.
- Explain purposes of nursing codes of ethics.
- Explain elements of the codes.
- Outline origins of ethical problem in nursing.
- Discuss on making ethical decision and models.
- Explain strategies to enhance ethical decision and practice.
a. DEFINITION
Ethics comes from the Greek word ethos, meaning character. “the study of what constitutes good and bad human conduct including related actions and values” .Attempts to establish norms or principles by which conduct can be judged. Concerned with what people ought to value and what behavior ought to be considered right and wrong.
b. PURPOSES OF NURSING CODES OF ETHICS
There are several purposes why nursing codes of ethics is important in nursing profession. Inform the public about the minimum standards of the profession and help them understand professional nursing conduct. It provides a sign of the profession’s commitment to the public it serves. Outline the major ethical considerations of the profession and provide ethical standards for professional behavior. It acts as a guide the profession in self-regulation. It is a reminder to nurses of the special responsibility they assume when caring for the sick.
c. WHO ESTABLISH CODES OF ETHICS ?
International, national and state nursing associations have established codes of ethics.The International Council of Nurses (ICN) first adopted a codes of ethics in 1953 – most recent revision (2005)
d. ELEMENTS OF THE CODES
What are the elements of the codes in nursing practices.
i. Nurses and People -The nurse’s primary professional responsibility is to people requiring nursing care. In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected. The nurse ensures that the individual receives sufficient information on which to base consent for care and related treatment. The nurse holds in confidence personal information and uses judgment in sharing this information. Share with the society the responsibility for initiating and supporting action to meet the health and social needs of the public. Nurse responsible to sustain and protect the natural environment from depletion, pollution, degradation, and destruction.
ii. Nurses and Practice - Carries personal responsibility and accountability for nursing practice, and for maintaining competence by continual learning. The nurse maintains a standard of personal health such that the ability to provide care is not compromised. The nurse uses judgment regarding individual competence when accepting and delegating responsibility. Maintains standards of personal conduct all the time which reflect well on the profession and enhance public confidence. Ensures the use of technology and scientific advances are compatible with the safety, dignity, and rights of people.
iii. Nurses and the profession - Assumes the major role in determining and implementing acceptable standards of clinical nursing practice, management, research and education. Active in developing a care of research-based professional knowledge. Acting through the professional organization, participates in creating and maintaining safe, equitable social and economic conditions in nursing.
vi. Nurses and co-workers - The nurse sustains a co-operative relationship with co-workers in nursing and other fields. The nurse take appropriate action to safeguard individuals, families and communities when their health is endangered by a co-worker or any other person.
9.2. ORIGINS OF ETHICAL PROBLEMS IN NURSING
Nurses growing awareness of ethical problem has occurred largely because of :
- Social and technological changes
- Nurses' conflicting loyalties and obligations
a. SOCIAL AND TECHNOLOGICAL CHANGES
Social changes – such as the women’s movement and a growing consumerism. A large people without health insurance, the high cost of health care. Technology creates new issues that did not exist in earlier time.
b. CONFLICTING LOYALITIES AND OBLIGATIONS
Unique position in the health care system nurses experience conflicts among their loyalties and obligations to the client, families, primary care providers, employing institutions and licensing bodies. According to code of ethics – nurse’s first loyalty is to the client. It is not always easy to determine which action best serves the client’s need.
c. MAKING ETHICS DECISIONS
Should be based on ethical principles and codes rather than on emotion, intuition, fixed policies, or precedent. A good decision is one that is in the client’s best interest and at the same time preserves the integrity of all involved. An important step in decision making is to determine whether a moral situation exist.
The following criteria may be used:
- A difficult choice exists between actions that conflict with the needs of one or more persons.
- Moral principles or frameworks exist that can be used to provide some justification for the action.
- The choice is guided by a process of weighing reasons.
- The decision must be freely and consciously chosen.
- The choice is affected by personal feelings and by the particular context of the situation.
9.3. ETHICAL DECISION-MAKING MODELS
a. Thompson and Thompson (1985).
• Review the situation to determine health problems, decision needs, ethical components, and key individuals.
• Gather additional information to clarify the situation.
• Identify the ethical issues in the situation.
• Define personal and professional moral positions.
• Identify moral positions of key individuals involved.
• Determine who should make the decision.
• Identify range of actions with anticipated outcomes.
• Decide on a course of action and carry it out.
• Evaluate/review results of decision/action.
b. Cassells and Redman (1989)
• Identify the moral aspects of nursing care.
• Gather relevant facts related to moral issue.
• Clarify and apply personal values.
• Understand ethical theories and principles.
• Utilize competent interdisciplinary resources.
• Propose alternative actions.
• Apply nursing codes of ethics to help guide actions.
• Choose and implement resolutive action.
• Participate actively in resolving the issue. Apply stat and federal laws governing nursing practice.
• Evaluate the resolutive action taken.
Being involved in ethical problems and dilemmas is stressful for the nurse. A good support system should be established such as team conferences and use of counseling professionals to allow expressing of their feelings.
9.4. STRATEGIES TO ENHANCE ETHICAL DECISION AND PRACTICE
The following strategies should be taken by a nurse to overcome the moral distress on the job:
- Become aware of your own values and ethical aspects of nursing.
- Be familiar with nursing codes of ethics.
- Seek continuing education opportunities to stay knowledgeable about ethical issues in nursing.
- Respect the values, opinions, and responsibilities of other health care professional that may be different from your own.
- Serve on institutional ethics committees.
- Strive for collaborative practice in which nurses' function effectively in cooperation with other health care professionals.
9.5. MANAGEMENT OF PERSONAL HEALTH INFORMATION
Keeping the client’s privacy is both a legal and moral mandate. The client must be able to trust that the nurses will reveal details of their situations only as appropriate for the health care. Nurses should help develop and follow security measures and policies.
INTRODUCTION SPECIFIC ETHICAL ISSUES IN NURSING
Nurses face ethical issues daily regardless of where they practice. They are faced with ethical decisions that can impact them and their patients. Ethics is the science relating to moral action and one’s value system. Nursing ethics provides the standards for professional behavior and is the study of principles of right and wrong conduct for nurses. Nursing ethics states the duties and obligations of nurses to their clients, other health professional, the profession and the community.
Ethics promotes the philosophical and theological study of morality, mental judgments and moral problems. Nurses adhere to certain ethical principle when caring for patients. These principles include beneficence which is doing no harm to the patient, maleficence which is doing harm to a patient for positive outcome, justice in allocating care based on need not status and patient autonomy which is respecting the patient’s right to make health decision
LEARNING OUTCOMES
At the end of the lecture, student will be able to :
- Discuss specific ethical issues in nursing.
- Explain step of decision making and the need.
- Discuss society role.
- Elaborate the ethical issues in nursing implications
- Prevent conflict with the principles of ethical nursing practice.
a. SPECIFIC ETHICAL ISSUES
Several factors contribute to the frequency of nurse's ethical issues:
Societal factors - Increased consumer awareness e.g., informed consent for treatments
and technological advances
b. ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS)
Because of its association with sexual behavior, illicit drug use, physical decline and death.
AIDS bears a social stigma. The American Nurses Association’s position on AIDS – the moral obligation to care for HIV-infected client cannot be set aside unless the risk exceeds the responsibility.
c.i. ABORTION
The debate continues between the sanctity of life and the right for a woman to control her own body. Conscience clauses give the caregiver the right to refuse to participate in abortions, but they cannot impose their values on the client. The client has a right to be educated about all choices.
Abortion is defined as expulsion of fetus and products of conception with fetus
weight less than 500gram.
c.ii. ABORTIONS IN MALAYSIA
Abortion laws provide specific guidelines for nurses about what is legally permissible. Section 312 of the Penal Code states that a termination of pregnancy is permitted in circumstances where there is risk to the life of the pregnant woman or threat of injury to her physical or mental health.
Although terminations are permitted, the law is nevertheless limited. Under the Penal Code it is the doctor alone who makes the decision as to whether a termination should be carried out. This is especially worrying in view of the results from the 2007 survey by the Reproductive Rights Advocacy Alliance of Malaysia (RRAAM) which found that only 57 per cent of 120 doctors and nurses surveyed knew that abortion is legal in certain circumstances.
c.iii. . COMPARISONS MADE WITH OTHER COUNTRIES
Abortion laws, generally, are historically framed as criminal offences and they tend to be amended later towards providing more liberal grounds for abortions. Exceptions added later range from ‘threat to life’ and ‘threat to physical or mental health’ up to ‘economic-social reasons’, and, ultimately, to allowing abortions ‘on demand’. Sometimes, specific conditions are stated, e.g. rape, fetal malformations, contraceptive failure, etc.
Examples given were Australia, Singapore, Vietnam, China – very liberal, permitting abortions on all the above grounds. The Philippines and Sri Lanka represent the other extreme, where abortions are restricted only in order ‘to save her life’. This has resulted in high rates of unsafe abortions and frequent hospital admissions for serious complications.
Malaysian law, by comparison, lies in between; it is ‘moderately permissive’. An important point to clarify: mental health under our Penal Code does not require psychiatric assessment.
Additional requirements: Third party authorization by a medical professional is required. The legal period allowed is 120 days and the woman’s consent is required. If she is not ‘quick’ with child, they are subject to up to three years imprisonment and/or payment of a fine. A woman usually considered to be ‘quick’ with child around the fourth month of pregnancy.
If the abortion results in the death of the woman and she has consented, the person performing the abortion is subject to up to 10 years imprisonment and payment of a fine .If the woman did not consent, the person is subject to up to 20 years imprisonment.
In conclusion:
Nurse needs to be aware of their code of professional conduct in matters dealing with abortion. Their role in health promotion especially in Reproductive Health would help women to make informed, decisions.
d. ORGAN DONATIONS
d.i. ORGAN TRANSPLANT
Ethical issues related to organ transplantation include allocation of organ, selling of body parts, involvement of children as potential donor, consent, clear definition of death and conflicts of interest between potential donors and recipients.
It means that "Organ donation" refers to donation of organs upon death. If a person is brain dead, certain organs like the cornea, heart, kidneys, liver, lungs, skin, and bones can be harvested to enable a transplant to take place and used to save more than one person's life. Process: tissues or organs are removed from a live, or recently dead, person to be used in another.
The procedure goes as - Donor gives the organs, Recipient gets the organs , People of all ages can become donors and the Organs can also come from animals (xenotransplantation)
SOCIETY’S ROLE
To increased public awareness regarding organ donation in order to develop a greater efforts to dispel public concerns in such that the organ donation can help with tragedy so much so it’s clearly understood that "organs wasted are lives lost”
d.ii. TYPES OF DONORS
Can ether be - Dead donors that almost all organs can be donated by someone dead but the organs have to reach the recipient within a few hours after the donor's death.
• Brain death
• Donation after cardiac death (DCD)
• Tissue donation
Or Live donors – from related and unrelated family members
d.iii. CONSENT POLICY FROM DONOR
Cadaver donation - Relatives provide consent OR State law may allow other surrogate consent.
Generally voluntary - opt In: Donor consents in advance / opt Out: Anyone who has not refused is considered a donor
While In live donation the donor consents - Parental for children give the consent
d.vi. ORGAN DONOR CRITERIA - The standard policy to follow are as indicated below:
• Age is generally less than 80 but is based on patient’s current medical history.
- Dead by neurologic criteria - “Brain Dead”
• Dead by cardio-pulmonary criteria
• Medical history is examined at the time of death.
- Free of HIV - All serologies are examined at time of death but HIV to HIV is possible.
d.v. TISSUES DONOR CRITERIA
Normally the donation occurs after cardiac death. The criteria to follow are.
• Age < 70
• Recovered within 24 hours after death if body is cooled in the first 12 hours.
• No active, transmissible disease
• No autoimmune disorder
The common tissues being transplanted are Heart valves, Pericardium, Skin, Bone -Whole or processed grafts, Veins, Fascia, Ligaments/Tendons, Eyes: Cornea, Sclera or Whole Eyes for Research
e. EUTHANASIA - END OF LIFES
It is an advance Directives – as indicated all 40 states have enacted advance directive legislation. Having the client complete these saves many moral and ethical decisions. Euthanasia and assisted suicide. Euthanasia is a Greek word meaning ‘good death’. It is sometimes call mercy killing.
It is defined - Euthanasia is generally defined as the act of killing an incurably ill person out of concern and compassion for the person’s suffering. The term euthanasia normally implies an intentional termination of life by another at the explicit request of the person/client who wishes to die.
e.i. TYPES OF EUTHANASIA
• Voluntary euthanasia: When the person who is killed has requested to be killed.
• Non-voluntary: When the person who is killed made no request and gave no consent.
• Involuntary euthanasia: When the person who is killed made an expressed wish to the contrary.
• Assisted suicide: Someone provides an individual with the information, guidance, and means to take his or her own life with the intention that they will be used for this purpose. suicide."
• Euthanasia By Action: Intentionally causing a person's death by performing an action such as by giving a lethal injection.
• Euthanasia By Omission: Intentionally causing death by not providing necessary and ordinary (usual and customary) care or food and water.
e.ii. PASSIVE EUTHANASIA
Hastening the death of a person by altering some form of support and letting nature take its own course is known as passive euthanasia. e.g., turning off respirators, halting medication, discontinuing food and water which allows the client to dehydrate or starve to death or failure to resuscitate.
Passive euthanasia also includes giving the client large doses of morphine to control pain. The likely hood that the pain killer can suppress respiration which cause death earlier. e.g., Administering such medication is regarding as ethical in most political jurisdictions and by most medical societies.
Passive euthanasia is now more commonly known as withdrawing or withholding life sustaining., or therapy (WWLST) e.g., withholding special attempts to revive a client.
e.iii. ACTIVE EUTHANASIA
Active euthanasia involves causing the death of a person through a direct action. The religious perspective indicated that Muslims are against euthanasia. Life is sacred. Euthanasia and suicide are not included among the reason allowed for killing in Islam. The reasons for euthanasia are due to unbearable pain, right to commit suicide or willingly to die
e. vi. EUTHANASIA AND ASSISTED SUICIDE
The ANA (American Nurses Association) states that both active euthanasia and assisted suicide are in violation of the Code for Nurses.
allowing a person to die by withholding or withdrawing measures to maintain life (withdrawing or withholding life-sustaining therapy. This is both legally and ethically more acceptable to most persons than assisted suicide.f. TERMINATION OF LIFE-SUSTAINING TREATMENT
Nurses must understand that a decision to withdraw treatment is not a decision to withdraw care. As the primary caregivers, nurses must ensure that sensitive care and comfort measures are given as the client’s illness progresses.
f.i. WITHDRAWING OR WITHHOLDING FOOD AND FLUIDS
It is generally accepted that providing food and fluids are administered by a tube to a dying patient or are given over along period to an unconscious client who is not expected to improve, then some consider it to be extraordinary. A nurse is morally obligate to withhold food and fluids (or any treatment) if it is determined to be more harmful to administer them than to withhold them. The nurse must also honor competent and informed clients’ refusal of food and fluids.
f.ii. ALLOCATION OF SCARE HEALTH RESOURCES
The moral principle of autonomy cannot be applied if it is not possible to give each client what he or she chooses. In this situation, health care providers may use the principle of justice – attempting to choose what is most fair to all. Some nurses are concerned that staffing in their institutions is not adequate to give the level of care they value. California is the first state to enact legislation mandating specific nurse-to-client ratios.
It clearly explained that the increase in technological advances and the growing numbers of elderly population have expanded the ethical dilemmas faced by elders and the healthcare profession. Providing them with competent care information and professional assistance as well as the highest quality of care and caring is of almost importance. The ethical problems faced by nurse involves issues on euthanasia, assisted suicide, termination of life sustaining treatment and or withdrawing/withholding food and fluids. And the nurses have to practice based on ethics and legislation (Law)
g.DO NOT RESUSITATE
It is defined as the legal ordered by the physician who care for the patient’s.
A DNR (Do Not Resuscitate) Oder or no code is a legal order written or a doctor's order initiated at the request of the patient who wishes and has decided not to have cardiopulmonary resuscitation (CPR) attempted in the event his or her heart or breathing stops.
A DNR is written to indicate that the goal of treatment is a comfortable, dignified death and that the further life-sustaining measures are not indicated.
g.i. PRINCIPLES OF DO NOT RESUSITATE
Consensus building is the most inclusive process for determining what is the best treatment for that individual, at that time, and in that place.
Normally the instructions being carried out according to: respect the patient’s wishes. Respect of life and care in dying. The right to know and to choose. Appropriate withholding and withdrawal of life sustaining treatment. A collaborative approach to care and transparency and accountability.
g.ii. CATERGORIES OF PATIENT FOR DNR
A competent patient who has stated his/her wish not to initiate or who has stated his/her wish to have life support withdrawn, Example: Competent patient have given clear wishes before the present episode of illness or those who have given do not resuscitate orders (DNR).
Terminal condition - Patient has a progressive, unrelenting terminal disease whose death is expected and in whom resuscitation represents a violation of the right to die with dignity.
Brain death - Brain death is perfectly legitimate and legal to withdraw all forms of life support once a diagnosis is made.
Other categories - Scoring system. APACHE (Acute Physiological and Chronic Health
Evaluation) - SAPS (Severe acute Physiological Score), Quality of life.h
g.iii. TYPES OF DNR
- Maximal (Restorative) Care Before Arrest, Then DNR
In this option, one requests the full scope of restorative care before the heart stops or before breathing stops. This may include Intubation, Cardiac monitoring, IVs, Drug therapy. Or if at any time during treatment the patient's heart or breathing stops, the patient will not be resuscitated; that is, personnel will not provide CPR, cardiac pacing, defibrillation or drug therapy.
- Limited (Palliative) Care Only Before Arrest, Then DNR
In this option, treatment given by emergency medical personnel may include Opening the airway by non-invasive means, Passive oxygen, controlling external bleeding, Positioning for comfort, Splinting, if necessary or transportation to hospital or designated facility capable of providing in-patient hospice care.
g.vi. THE PALLIATIVE CARE THAT NEEDS TO BE CONSIDERED ARE ONLY BEFORE ARREST, THEN DNR
If at any time the person's heart or breathing stops, the emergency medical personnel will not provide CPR, cardiac pacing, defibrillation, or drug therapy.
g.v. STEPS IN DECISION MAKING FOR DNR
- Medical consensus - It is essential that the primary physician and the intensive care team have agreed on a consensus before any decision is taken.
- Nursing consensus -it is essential that they also are in support of the decision to withhold or withdraw therapy.
Communication / Documentation: DNR form / BHT (red pen)
g.vi. THE ANA(2003) MAKES THE FOLLOWING RECOMMENDATIONS RELATED TO DNR ORDERS
- The competent client’s values and choices should always be given highest priority.
- When the client is incompetent, an advance directive or the proxy decision makers acting for the client should make health care treatment decision.
- A DNR decision should always be the subject of explicit discussion between the client, client’s family, any designated decision maker acting on the client’s behalf, and the health care team.
- DNR orders must be clearly documented, reviewed and updated periodically to reflect changes in client’s condition.
- A DNR order is separated from other aspects of a client care and does not imply that other types of care should be withdrawn.
g.vii. STRATEGIES TO ENHANCES ETHICAL DECISION AND PRACTICE
The following strategies should be taken by a nurse to overcome the moral distress on the job:
Become aware of your own values and ethical aspects of nursing. Be familiar with nursing codes of ethics. Seek continuing education opportunities to stay knowledgeable about ethical issues in nursing. Respect the values, opinions, and responsibilities of other health care professional that may be different from your own. Serve on institutional ethics committees. Strive for collaborative practice in which nurses' function effectively in cooperation with other health care professionals