Values

• Values — enduring beliefs or attitudes about the worth of an individual, object, idea, or action.

  • Influence decisions and actions, including nurses’ ethical decision-making.

• Value systems — give direction to life and form the basis of behavior—especially behavior based on decisions or choices.

• Beliefs — interpretations or conclusions that people accept as true.

  • Based more on faith than fact.

  • Lasts briefly.

  • Judged as correct or incorrect.

• Attitudes — mental positions or feelings toward an individual, object, or idea.

  • Lasts overtime.

  • Judged as bad or good, positive or negative.

  • have thinking and behavioral aspects and vary greatly among individuals.

Values Transmission

• Personal Values — internalized values; needed this for sense of individuality.

• Professional Values — acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers.

  • Five values essential for the professional nurse:

    • Altruism — concern for the welfare and well-being of others.

      • Reflected by the nurse’s concern for the welfare of patients, other nurses, and other healthcare providers.

    • Autonomy — Right to self-determination.

      • Reflected when the nurse respects patients’ rights to make decisions about their healthcare.

    • Human dignity — the respect for the inherent worth and uniqueness of individuals and populations.

      • Reflected when the nurse values and respects all patients and colleagues.

    • Integrity — acting in accordance with an appropriate code of ethics and accepted standards of practice.

      • Reflected in professional practice when the nurse is honest and provides care based on an ethical framework that is accepted within the profession.

    • Social justice — acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability, or sexual orientation.

Values Clarification

• Values clarification — a process by which people identify, examine, and develop their own individual values.

  • Choosing (Cognitive) — Beliefs are chosen…

    • Freely, without outside pressure

    • From among alternatives

    • After reflecting and considering consequences.

  • Prizing (Affective) — Chosen beliefs are prized and cherished.

  • Acting (Behavioral) — Chosen beliefs are…

    • Affirmed to others

    • Incorporated into one’s behavior

    • Repeated consistently in one’s life

Clarifying Client Values

• List alternatives. Make sure that the client is aware of all alternative actions.

  • “Are you considering other courses of action?”

  • “Tell me about them.”

• Examine possible consequences of choices. Make sure the client has thought about possible results of each action.

  • “What do you think you will gain from doing that?”

  • “What benefits do you foresee from doing that?”

• Choose freely.

  • “Did you have any say in that decision?”

  • “Do you have a choice?”

• Describe feelings about the choice. Some clients may not feel satisfied with their decision.

  • Some people feel good after a decision is made; others feel bad. How do you feel?”

• Affirm the choice.

  • “How will you discuss this with others (family, friends)?”

• Act with a pattern.

  • “How many times have you done that before?”

  • “Would you act that way again?”

Ethics and Morality

• Ethics — a method of inquiry that helps people to understand the morality of human behavior.

  • the practices or beliefs of a certain group.

  • the expected standards of moral behavior of a particular group as described in the group’s formal code of professional ethics.

• Bioethics — ethics applied to human life or health.

• Nursing ethics — ethical issues that occur in nursing practice.

• Morality — private, personal standards of what is right and wrong in conduct, character, and attitude.

• Moral issues — concerned with important social values and norms.

• Laws reflect the moral values of a society, and they offer guidance in determining what is moral.

  • an action can be legal but not moral

• Moral Development — the process of learning to tell the difference between right and wrong and of learning what ought and ought not to be done.

Moral Frameworks

• A moral framework guides moral decisions, but it does not determine the outcome.

Three types of moral theories

• Consequence-based (teleological) theories — look to the outcomes (consequences) of an action in judging whether that action is right or wrong.

  • Utilitarianism — views a good act as one that is the most useful—that is, one that brings the most good and the least harm to the greatest number of people.

    • often used in making decisions about the funding and delivery of healthcare.

    • focuses in issues of fairness.

• Principles-based (deontological) theories — involve logical and formal processes and emphasize individual rights, duties, and obligations.

  • The morality of an action is determined not by its consequences but by whether it is done according to an impartial, objective principle.

• Relationships-based (caring) theories — emphasize courage, generosity, commitment, and the need to nurture and maintain relationships.

  • stress individual rights, but caring theories promote the common good or the welfare of the group.

Moral Principles

• Moral principles — statements about broad, general, philosophical concepts such as autonomy and justice.

  • Moral rules — specific descriptions for actions.

• Autonomy — refers to the right to make one’s own decisions.

  • Inward autonomy — autonomy in which nurses have the ability to make choices.

  • Outward autonomy — autonomy in which the nurses’ choices are not limited or imposed by others.

• Nonmaleficence — It is the duty to “do no harm.”

  • Unintentional harm — occurs when the risk could not have been anticipated.

• Beneficence — It means “doing good.”

• Justice — frequently referred to as fairness.

• Fidelity — It means to be faithful to agreements and promises.

• Veracity — It refers to telling the truth.

• Accountability — Answerable, or to give an account or defense to oneself and others for one’s own choices, decisions and actions as measured against a standard.

• Responsibility — the blameworthiness or praiseworthiness that one bears for one’s conduct or the performance of duties.

Nursing Ethics

Nursing Codes of Ethics

• Code of ethics — a formal statement of a group’s ideals and values.

  • a set of ethical principles that…

    • is shared by members of the group,

    • reflects their moral judgments over time, and

    • serves as a standard for their professional actions.

• Purposes of Nursing codes of ethics

  • Inform the public about the minimum standards of the profession and help them understand professional nursing conduct.

  • Provide a sign of the profession’s commitment to the public it serves.

  • Outline the major ethical considerations of the profession.

  • Provide ethical standards for professional behavior.

  • Guide the profession in self-regulation.

  • Remind nurses of the special responsibility they assume when caring for the sick.

Origins of Ethical Problems in Nursing

• Social and Technologic Changes

  • Women’s movement; growing consumerism.

  • High number of people without health insurance.

  • High-cost of health care and workplace

• Conflicting Loyalties and Obligations

  • Conflicts among loyalties.

    • A nurse’s first loyalty is to the client.

  • Conflict among feeling the need to support co-workers in their efforts to improve working conditions, feeling the need to ensure clients receive care and are not abandoned, and feeling loyalty to the hospital employer.

Making Ethical Decisions

• An important first step in ethical decision making is to determine whether a moral situation exists.

  • A difficult choice exists between actions that conflict with the needs of one or more people.

  • 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.

• Responsible ethical reasoning is rational and systematic.

  • It should be based on ethical principles and codes rather than on emotions, intuition, fixed policies, or precedent.

• A good decision is in the client’s best interest and at the same time preserves the integrity of all involved.

• Examples of Nurses’ Obligations in Ethical Decision Making

  • Maximize the client’s well-being.

  • Balance the client’s need for autonomy with family members’ responsibilities for the client’s well-being.

  • Support each family member and enhance the family support system.

  • Carry out hospital policies.

  • Protect other clients’ well-being.

  • Protect the nurse’s own standards of care.

• Moral Distress — occurs when you know the ethically correct action to take but you are constrained from taking it.

• The 4 A’s to Rise Above Moral Distress

  • The nurse asks whether signs of moral distress are present, affirms a commitment to addressing the distress, assesses the sources and severity of the distress plus readiness to act, and acts to implement a plan to reduce the distress.

Specific Ethical Issues

Aids

• According to an ANA position statement, the moral obligation to care for a client cannot be set aside unless the risk to the caregiver exceeds the responsibility.

• Questions arise as to whether testing of all providers and clients should be mandatory or voluntary and whether test results should be released to insurance companies, sexual partners, or caregivers.

Abortion

• Debate continues, pitting the principle of sanctity of life against the principle of autonomy and a woman’s right to control her own body.

• Most state laws have provisions known as conscience clauses that permit individual primary care providers and nurses, as well as institutions, to refuse to assist with an abortion if doing so violates their religious or moral principles.

• Nurses have no right to impose their values on a client. Nursing codes of ethics support clients’ rights to information and counseling in making decisions.

Organ and Tissue Transplantation

• Ethical issues related to organ transplantation include allocation of organs, selling of body parts, involvement of children as potential donors, consent, clear definition of death, and conflicts of interest between potential donors and recipients.

• An individual’s religious beliefs may also present conflict.

• Individuals’ spiritual beliefs and views on when human life begins have an impact on their opinions about stem cell research.

  • Stem cell research — the foundation for cell-based therapies in which stem cells are induced to differentiate into the specific cell type required to repair damaged or destroyed cells or tissues.

    • Both embryonic and adult cells are used in this research.

    • Embryonic cells are derived from a 5-day preimplantation embryo.

    • Adult cells are undifferentiated cells found in differentiated tissue.

End-of-Life Issues

• Advance Directives

  • These direct caregivers as to the client’s wishes about treatments, providing an ongoing voice for clients when they have lost the capacity to make or communicate their decisions. 

• Euthanasia and Assisted Suicide

  • Euthanasia — mercy killing.

  • Active euthanasia — involves actions to bring about the client’s death directly, with or without client consent.

  • Assisted Suicide — giving clients the means to kill themselves if they request it.

  • Passive euthanasia — withdrawing or withholding life-sustaining therapy; involves the withdrawal of extraordinary means of life support and allowing the client to die of the underlying medical condition.

• Termination of Life-Sustaining Treatment

  • Antibiotics, organ transplants, and technologic advances help to prolong life, but not necessarily to restore health.

  • Nurses must understand that a decision to withdraw treatment is not a decision to withdraw care.

  • Nurses must ensure that sensitive care and comfort measures are given as the client’s illness progresses.

• Withdrawing or Withholding Food and Fluids

  • It is part of the nurse’s duty to provide food and fluids to the patients.

  • When food and fluids are administered by tube to a dying client, or are given over a long period to an unconscious client who is not expected to improve, then some consider it to be an extraordinary, or heroic, measure.

  • A nurse is morally obligated to withhold food and fluids (or any treatment) if it is determined to be more harmful to administer them than to withhold them.

Allocation of Scarce Health Resources

• This includes organ transplants, artificial joints, and the services of specialists.

• The moral principle of autonomy cannot be applied if it is not possible to give each client what he or she chooses.

• With a nationwide shortage of nurses, an ethical dilemma arises when, in order to provide adequate staffing, facilities must turn away needy clients.

Management of Personal Health Information

• Privacy is both a legal and ethical mandate.

• Respect clients’ privacy and confidentiality.

• Clients must be able to trust that nurses will reveal details of their situations only as appropriate and will communicate only the information necessary to provide for their healthcare.

Advocacy

• Advocate — one who expresses and defends the cause of another.

• Values Basic to Client Advocacy

  • The client is a holistic, autonomous being who has the right to make choices and decisions.

  • Clients have the right to expect a nurse–client relationship that is based on shared respect, trust, collaboration in solving problems related to health and healthcare needs, and consideration of their thoughts and feelings.

  • It is the nurse’s responsibility to ensure the client has access to healthcare services that meet health needs

The Advocate’s Role

• The overall goal of the client advocate is to protect clients’ rights.

• An advocate…

  • informs clients about their rights and provides them with the information they need to make informed decisions.

  • supports clients in their decisions, giving them full or at least mutual responsibility in decision making when they are capable of it.

  • must be careful to remain objective and not convey approval or disapproval of the client’s choices.

  • requires accepting and respecting the client’s right to decide, even if the nurse believes the decision to be wrong.

Advocacy in Home Care

• The client’s autonomy must be respected.

• Limited resources and a lack of client care services may shift the focus from client welfare to concerns about resource allocation.

• Financial considerations can limit the availability of services and materials, making it difficult to ensure that client needs are met.

Professional and Public Advocacy

• A nurse needs an understanding of the ethical issues in nursing and healthcare, as well as knowledge of the laws and regulations that affect nursing practice and the health of society.

• Being an effective client advocate involves the following:

  • Being assertive

  • Recognizing that the rights and values of clients and families must take precedence when they conflict with those of healthcare providers

  • Being aware that conflicts may arise over issues that require consultation, confrontation, or negotiation between the nurse and administrative personnel or between the nurse and a primary care provider

  • Working with community agencies and lay practitioners

  • Staying knowledgeable about the legislation relevant to the client population.

  • Knowing that advocacy may require political action.