Ethical Decision Making and the Nursing Process

Ethical Nursing Care
In the complex modern world, we are surrounded by ethical issues in all facets of our lives. Consequently, there has been a heightened interest in the field of ethics, in an attempt to gain a better understanding of how these issues influence us. Specifically, in health care the focus on ethics has intensified in response to controversial developments, including advances in technology and genetics, as well as diminished health care and financial resources. Today, sophisticated technology can prolong life well beyond the time when death would have occurred in the past. Expensive experimental procedures and medications are available for attempting to preserve life, even when such attempts are likely to fail. The development of technological support has had an influence on all stages of life. For example, the prenatal period has been influenced by genetic screening, in vitro fertilization, the harvesting and freezing of embryos, and prenatal surgery. In the early stages of life, premature infants are given a chance for survival by the use of technical support. Children and adults who would have died as a result of organ failure are living longer because of organ transplantation. Technological advances have also contributed to an increase in the average life expectancy. These advances in technology, however, have been a mixed blessing. Questions have been raised about whether, and under what circumstances, it is appropriate to use such technology. Although many individuals are afforded a better quality of life, others face extended suffering as a result of efforts to prolong life, usually at great expense. Ethical issues also surround those practices or policies that seem to allocate health care resources unjustly on the basis of age, race, gender, disability, or social mores.

Domain of Nursing Ethics

The ethical dilemmas a nurse may encounter in the medical surgical arena are numerous and diverse. An awareness of underlying philosophical concepts will help the nurse to reason through these dilemmas. Understanding the role of the professional nurse in ethical decision making will assist nurses in articulating their ethical positions and in developing the skills needed to make ethical decisions.

Ethics versus Morality
The terms ethics and morality are used to describe beliefs about right and wrong and to suggest appropriate guidelines for action. In essence, ethics is the formal, systematic study of moral beliefs, whereas morality is the adherence to informal personal values. Because the distinction between the two is slight, they are often used interchangeably.

Ethics Theories
One classic theory in ethics is teleologic theory or consequentialism, which focuses on the ends or consequences of actions. The most well-known form of this theory, utilitarianism, is based on the concept of “the greatest good for the greatest number.” The choice of action is clear under this theory, because the action that maximizes good over bad is the correct one. The theory poses difficulty when one must judge intrinsic values and determine whose good is the greatest. Additionally, the question must be asked whether good consequences can justify any amoral actions that might be used to achieve them. Another theory in ethics is the deontologic or formalist theory, which argues that moral standards or principles exist independently of the ends or consequences. In a given situation, one or more moral principles may apply. The nurse has a duty to act based on the one relevant principle, or the most relevant of several moral principles.
Problems arise with this theory when personal and cultural biases influence the choice of the most primary moral principle.

Moral Situations
Many situations exist in which ethical analysis is needed. Some are moral dilemmas, situations in which a clear conflict exists between two or more moral principles or competing moral claims, and the nurse must choose the lesser of two evils. Other situations represent moral problems, in which there may be competing moral claims or principles but one claim or principle is clearly dominant. Some situations result in moral uncertainty, when one cannot accurately define what the moral situation is, or what moral principles apply, but has a strong feeling that something is not right. Still other situations may result in moral distress, in which the nurse is aware of the correct course of action but institutional constraints stand in the way of pursuing the correct action. For example, a patient tells a nurse that if he is dying he wants everything possible done. The surgeon and family have made the decision not to tell the patient he is terminally ill and not to resuscitate him if he stops breathing. From an ethical perspective, patients should be told the truth about their diagnoses and should have the opportunity to make decisions about treatments. Ideally, this information should come from the physician, with the nurse present to assist the patient in understanding the terminology and to provide further support, if necessary. A moral problem exists because of the competing moral claims of the family and physician, who wish to spare the patient distress, and the nurse, who wishes to be truthful with the patient as the patient has requested. If the patient’s competency were questionable, a moral dilemma would exist because no dominant principle would be evident. The nurse could experience moral distress if the hospital threatens disciplinary action or job termination if the information is disclosed without the agreement of the physician or the family, or both. It is essential that nurses freely engage in dialogue concerning moral situations, even though such dialogue is difficult for everyone involved. Improved interdisciplinary communication is supported when all members of the health care team can voice their concerns and come to an understanding of the moral situation. The use of an ethics consultant or consultation team could be helpful to assist the health care team, patient, and
family to identify the moral dilemma and possible approaches to the dilemma. The nurse should be familiar with agency policy supporting patient self-determination and resolution of ethical issues. The nurse should be an advocate for patient rights in each situation.


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