Chapter 13 Ethical Decision Making Dr Waddah D’emeh Dr. Waddah D'emeh.

Chapter 13

Ethical Decision Making

Dr Waddah D’emeh

Dr. Waddah D'emeh

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Introduction Changes in interprofessional roles, advances in medical technology, availability of information online, revisions in patient care delivery systems, and heightened economic constraints, have increased the complexity of ethical issues in the health care setting.

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Nurses in all areas of health care routinely encounter disturbing moral issues, yet the success with which these dilemmas are resolved varies significantly. As the complexity of issues intensifies, the role of the advanced practice nurse (APN) becomes particularly important in the identification, deliberation, and resolution of difficult moral problems.

Although all nurses are moral agents, APNs are expected to be leaders in resolving moral problems, working to create ethical practice environments, and promoting social justice in the larger health care system. Dr. Waddah D'emeh

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“We need to develop our hearts as well as our minds” Hope 2004

04/21/23 Dr. Waddah D'emeh

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APN Role in Moral and Ethical IssuesEthical decision making is a core

competency of APNs; they are leaders in:Recognizing and resolving moral issuesCreating ethical practice environmentsPromoting social justice in the larger

health care system

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QUALITIES OF ETHICAL NURSES

Moral integrity: truthfulness, honesty, courage.

Concern: advocacy & power.

Culturally sensitive care.

Respect for others.

Confidentiality.

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Types of Moral ProblemsMoral dilemma: Occurs when obligations

require or appear to require that a person adopt two (or more) alternative actions, but the person cannot carry out all the required alternatives

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Moral uncertainty: The right action is not clear

Moral distress: The right action is clear, but the actor feels constrained from carrying

out action (because of institutional obstacles)(Adapted from Jameton, 1984, 1993)


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Moral Distress: A Newer Definition“Moral distress is the experience of being

seriously compromised as a moral agent in practicing in accordance with accepted professional values and standards. It is a relational experience shaped by multiple contexts, including the socio-political and cultural context of the workplace environment.”(Varcoe et al., 2012, p. 60)

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Ethical Dilemma ThemesCommunicationInterdisciplinary ConflictManagement of Multiple

Commitments and Obligations

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Communication GoalsProblem: Erosion of open and

honest communicationSome ethical disputes reflect inadequate

communication rather than a difference in values.

All team members are accountable for providing succinct and precise information

Listening is as crucial as verbal skillsFocus on common goal of patient care

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COMMUNICATION

Clear and definitive communication with patients and families will increase understanding, lead to more knowledgeable decision making, and may improve compliance with current therapies.

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Listening involves recognizing and appreciating various perspectives.

Allow others the necessary time to form and present their thoughts and ideas.


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Interdisciplinary ConflictDiffering positions can lead to creative

and collaborative decision making or to a breakdown in communication

Interdisciplinary theme prevalent in presentation and resolution of ethical problems

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INTERDISCIPLINARY INVOLVEMENTIssues

Refusal of treatment.End-of-life decision making.Cost containment.Confidentiality.

Moral dilemmas that often surround end-of-life decision making provide an excellent example of interdisciplinary issues that call for a collaborative approach.

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Multiple CommitmentsFidelity: Obligation to be faithful to

commitments and promisesAPN fidelity to self in addition to:

The patient and family Physicians and other colleaguesThe institution or employer The larger profession

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Have you experienced any ethical dilemma during your career?

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Examples of Ethical Issues: Primary Care Insurance reimbursementPatient refusal of appropriate careLack of power to effect change Being asked to see an excessive

number of patients

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Examples of Ethical Issues:Acute and Chronic Care

• Pain management

• End-of-life care

• Advance directives(Shannon, Foglia, & Hardy, 2009)

• Assisted suicide

• Confidentiality

• Transmitting health information electronically

(Rajput & Bekes, 2002)

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Examples of Ethical Issues: Societal Issues

Cost containment vs. quality of careScientific and technological advancesEthical problems related to research:

Informed consent Protecting vulnerable patients from undue

riskProtecting subject privacy

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Examples of Ethical Issues: Access and Justice Issues

Issues of social justice and equitable access

Allocation of scarce health care resources“Brain drain”: leaving nurses from

underdeveloped to developed countries.

E.g. organ transplantations Tension in caring for the individual

patient vs. the larger population

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Legal Issues Legal precedent has emerged,

reflecting changes in society’s moral consensus

Often, no relevant law → ethical decision making

Judicial aim is to interpret law, not satisfy ethical concerns of all parties

Law may contribute to creation of new dilemmas

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Phases of Ethical Decision Making Competency Development

Phases are sequential

Phases 1 and 2 should be taught in graduate education

Phases 3 and 4 evolve as APNs mature in roles

Phase 4 relies on competencies

of DNP-prepared APNs

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Ethical Decision Making Competency Phase 1: Knowledge development Phase 2: Knowledge application Phase 3: Creating an ethical

environment Phase 4: Promoting social justice

within the health care system

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Phases of Development of Core Competency for Ethical Decision Making

See Table 13-1

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Phase Knowledge Skill/behavior

Phase 1:

knowledge development-moral sensitivity.

Ethical theoriesEthical issues in specialtyProfessional codeProfessional standards Legal precedent

Sensitivity to ethical dimensions of clinical practice( values clarifications-sensitivity to fidelity conflict).Gather relevant literature related to problems identified.Evaluate practice setting for congruence with literature.Identify ethical issues in the practice setting and bring the attention to the other team members.

Phases of development of core competency for ethical decision-making

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Phase Knowledge Skill/behavior Phase 2:

knowledge application

Ethical decision-making modelsMediation/facilitation strategies

Apply ethical decision-making models to clinical problems.Use of skilled communication regarding ethical issues.Facilitate decision-making by using select strategies.

Phase 3:

Creating an ethical environment.

Preventive ethicsAwareness of environmental barriers to ethical practice.

Role-model collaborative problem solving.Mentor others to develop ethical practice.Address barriers to ethical practice through system changes.


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Phase Knowledge Skill/behavior Phase 4:

Promoting social justice within the health care system

concepts of justice.Health polices affecting a specialty population.

ability to analyze the policy process.Advocacy, communication and leadership skills.Involvement in healthy policy initiative supporting social justice.


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Phase 1: Knowledge DevelopmentGains knowledge of ethical standards and

compares these to current practiceDevelops moral sensitivity through

clarification of personal and professional values

Distinguishes ethical problems from moral distress and other complex clinical problems

Allows APNs to develop language necessary to articulate ethical concerns in interprofessional environment

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Developing an Educational Foundation

Education in ethical theories, principles, rules, and moral concepts provides foundation for developing skills in ethical reasoningBuilding trust in APN–patient relationshipProfessionalism and patient advocacyResource allocation decisionsIndividual vs. population responsibilitiesManaging tension between business and

professional ethicsContinuing education programs effective and

necessary

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Content of Ethical Knowledge: Theories and Approaches

Principle-based approachAlternative Ethical Approaches

CasuistryNarrative ethicsVirtue-based ethicsFeminist EthicsCare-based ethics

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Deontology (formalistic, principle, duty-based system)Based on the discovery

and confirmation of a set of morals or rules that govern the ethical dilemma to be resolved

Principles are absolute and unchanging

Ethical Theories/Systems

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Deontology (continued)Principles are based on those

fundamental values that undergird all major religions—are universal

Most basic principle is “survival of the species” through social cooperation

Focused on the principles of right and wrong

Principles echo those in the Bill of Rights

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Ethical Theories/Systems

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Content of Ethical Knowledge: Principles Respect for personsAutonomyBeneficenceNonmaleficenceJusticeVeracityConfidentialityRole Fidelity

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Autonomy Self-determinationElements:

The ability to decide.The power to act on your decisionsA respect for the individual autonomy of others.

Applications to this principle:1- informed consent2- patient self-determination act (1990)

Other applications? Maintaining privacy, confidentiality, refusal of

treatment and other patient’s rights.When restrictions can be applied to individual’s

autonomy??

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VeracityThe duty to tell the truth and not to deceive others (how does it relate to autonomy?)When faced with situations in which lying seems a rational solution, other alternatives must be sought.The harm to patient autonomy and the potential loss of practitioner credibility makes lying to patients a practice that in almost all cases should be avoided.

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THERAPEUTIC PRIVILEGE Therapeutic Privilege :

The practice of withholding information from patient in the belief that disclosure is medically contraindicated.

Nurses might use therapeutic privilege when:-

They are trying to protect the patient from sad & heart breaking news.They do not know the fact.

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Beneficence and Nonmaleficence Health care professionals try to do good

(beneficence), but if for some reason they cannot do good, they at least do no harm.

Beneficence: The duty to do good and prevent or remove harm.

Nonmaleficence: do no harm (medical futility), (slippery slope argument) & (double effect).

Concepts related to Nonmaleficence: negligence and extraordinary or ordinary treatments.

Principles of Nonmaleficence: • Do not kill.• Do not cause needless pain.• Do not incapacitate others

⇒ The important point to notice is that each of these principles can be met by doing nothing.

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Confidentiality A patient’s basic right to expect the information he gives a health care practitioner to be held undisclosed. An important aspect of the trust that patient’s place in health care professionals.When can health care professional override confidentiality?? (Harm Principle)Child abuseContagious diseaseSTD’sWounds caused by guns and knivesCases in which identifiable third parties would be placed at risk by failure to disclose information.

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Role fidelityThe duty to honor commitmentsSelf-regulation is one of the key elements of profession. Professional code of ethics are important documents in the process of self-regulation.Under no circumstances may the practitioner place his financial interests above the welfare of his patients.Gate keeping within role duty and fidelity requires the individual practitioners be responsible not only for their standard of practice but works to protect the community, patients and our specialties from abuse of other practitioners.

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Formal JusticeJustice: refers to fairness, treating people equally and without prejudice, and equitable distribution of benefits and burdens.

Social justice: “veil of ignorance” Rawls(1971).This concept means that if people had a veil to shield them from their own or others’ economics, social, and class standing, each person would be likely to make justice-based decisions from a position that is free from biases.

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Ethical Theories/SystemsUtilitarianism (teleological,

consequentialism, situation ethics)

An ethical system of utility

Good: happiness, pleasure, or lack of discomfort and pain

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Ethical Theories/SystemsMain principles of utilitarianism

Greatest good for the greatest number The end justifies the meansNo set rules or principles to govern day-

to-day decisionsAll decisions depend on the situationMoral decisions exist to serve a

purpose: the greatest good for the greatest number of people

Group “happiness” or good supercedes the good of the individual

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Casuistry• Casuistry is based in Judeo – Christian history. • When people use casuistry, they make decisions

inductively based on individual cases.• When people use casuistry, their ethical decision

making begins as a bottom-up approach by considering the details of specific cases rather than beginning from the top down by applying absolute rules and principles.

• In Catholic history, the practice of persons individually confessing their sins to priests to receive absolution reflects the use of casuistry.

• Today, casuistry is often the method used by health care ethics committees to analyze the ethical issues surrounding specific patient cases.

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Example• While a principle-based approach might claim

that lying is always morally wrong, the casuist would argue that, depending upon the details of the case, lying might or might not be illegal or unethical. The casuist might conclude that a person is wrong to lie in legal testimony under oath, but might argue that lying actually is the best moral choice if the lie saves a life

• Abortions?

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Narrative Ethics• Most people from childhood obtain moral

education about character development from stories, such as fairy tales.

• Similarities to virtue ethics and casuistry?• How can culture affect the narrative ethics?• “narrative approach to bioethics focuses on the

patients themselves: these are the moral agents who enact choices” (Charon & Montello, 2002 p. xi).

• No one story should be accepted without critical reflection.

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It emphasized that the excellence of one’s character and considerations of what sort of person one wants to be.

Since the time of ancient Greek virtues have referred to excellences in regard to persons or objects being the best that they can be in accordance with their purpose. Even an inanimate.

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Virtue ethics• Virtues for humans :are habitual, excellent traits that

are intentionally developed throughout one's life.• Aristotle's approach to virtue ethics is grounded in two

categories of excellence: Intellectual virtues (comes into existence and increases as a result of teaching) and character or moral virtues (results from habituation). These virtues cannot be distinctly separated.

• Most virtues consistent with the extremes of excess and deficiency.

• There is a “Golden Mean”• Courage as a virtue, the extremes of rashness and

cowardice.

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Feminist Ethics • One critical theory that is widely used by nurses.• Under this broad feminist approach is the ethic of care that

originated from the Kohlberg-Gilligan.• Focused on evaluating ethically related situations in terms of

how these situations affect women.• An ethic of care is grounded in the moral experiences of women

and feminist ethics.• Ethic of care emphasizes the importance of traditionally

feminine traits such as love, compassion, sympathy, and concern about the well – being of other people.

• The role of emotions in moral reasoning and behavior is accepted as being a necessary and natural compliment to rational thinking.

• This position distinguishes an ethic of care from an ethic of justice and duty- based ethics that emphasize the preeminence of reason and minimize the importance of emotion in guiding moral reasoning and the moral nature of one's relationships.

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Care-based ethics

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Professional Codes and Guidelines

ANA Code of Ethics for Nurses (2001)Guidelines from professional organizationsICN Code of Ethics for Nurses (2012)Jordanian code of Ethics, JNMC (2011)

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Content of Ethical Knowledge: Values Values: Enduring beliefs that guide choices and

decisions in conflict resolution (Ludwick & Silva, 2000)

Reasoning: involves thinking for oneself to determine if one’s conclusion are based on good, logical, foundations. Giving things a reason to exist

Moral reasoning: pertains to reasoning focused on moral or ethical issues.

Values awareness includes understanding of complex interplay between cultural values and ethical decision making

(Buryska, 2001; Ludwig & Silva, 2000)

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Professional BoundariesPower differential in patient–provider

relationshipIntimacy because of physical contactAccess to personal and private information

Boundary violationsThe limits and expectations of the relationship

are breached Must be immediately confronted, and culpable

individual must be removed from interaction with patient

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Phase 2: Knowledge ApplicationApplying knowledge developed in Phase 1 to the

clinical practice areaTranslation of ethical knowledge to moral action An APN accepts responsibility to be a full

participant in the resolution of moral dilemmasResources for development

Ethics committees (functions are: policy formation, case review, and education)

Institutional review boards Mentoring Active seeking of opportunities for ethical

dialogue

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Knowledge Application: Ethical Decision Making

Key step is information gathering, including contextual information and clarifying problem

Problem identification Essential component of resolution of ethical

dilemma is moral action

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Sample Ethical Decision Making Framework

See Box 13-41. Gather information2. Determine that the problem is an

ethical one and identify the type3. Use ethical theories or approaches to

analyze the problem4. Explore the practical alternatives5. Complete the action6. Evaluate the process and outcome

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Knowledge Application: Strategies for Ethical Resolution

APN as facilitatorObjective to achieve integrity-preserving

solutionStrategies:

CollaborationCompromiseAccommodationCoercionAvoidance

When “avoidance” is the norm in dealing with ethical conflict → routinization → nurses became accustomed and desensitized to ethical conflicts

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Phase 3: Creating an Ethical Environment

The experienced APN: Goes beyond addressing individual situations of

ethical conflictEmpowers others through role modeling,

mentoring, and informal education, such as ethics rounds and case discussion

Coaches and teaches patients/families in ethical decision making

Creates ethical environmentUses preventive ethics

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Phase 3: Preventive Ethics Extension of ethical decision making

process; problems are proactively addressed

Requires early identification of potential values conflicts and exposure of power imbalances

Emphasis placed on enhanced autonomy and inclusion of all parties in resolution

Cultivates ethically responsive environment of ongoing ethical inquiry

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Phase 4: Promoting Social Justice Within the Health Care System

The knowledge and skills developed in Phases 1, 2, and 3 are applied to the wider social sphere

The AACN’s DNP essentials emphasize social justice and need for systems leadership

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Phase 4: Social JusticeThe APN who reaches Phase 4:

Has an awareness of specific policy issues affecting the specialty population

Develops skills through involvement in institutional or community policy groups

Acts as a consultant to policy makersMay serve on an expert panel crafting

policy for specialty groups

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Phase 4: Social Justice (Cont.)Knowledge required:

Distributive justice: the equitable allocation of scarce resources

Restorative justice: the duty owed to those who have been systematically disadvantaged through no fault of their own

Health policy processSpecific health policies for specialty

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Evaluation of the Ethical Decision-Making Competency

Process evaluationOverview of moral disagreementInterpersonal skills employedInteractions between both parties in

conflictProblems encountered during phases of

resolutionIs particularly important in phase 4

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Evaluation of the Ethical Decision-Making Competency (Cont.)

Outcome evaluationAcknowledges creative solutions and

celebrates moral actionIncludes short and long term solutions,

and satisfaction of all parties.Prevents recurrence by identifying

patternsAddresses “moral residue” and the

Crescendo Effect

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Barriers Internal to the APN• APN’s lack of knowledge and confidence; sense

of powerlessness

• Lack of time

Strategies to Overcome Internal APN Barriers: Seek out opportunities for ethics educationValues clarification exercisesGain empowerment through role modelingResolve a dilemma in stagesEnlist aid of other colleagues

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Interprofessional Barriers• Differing approaches among health care team

membersStrategies to Overcome Interprofessional Barriers :

Open communicationCooperationDevelop climate of mutual respect and shared

valuesDemonstrated competenceAccountability for role and actionsDeveloping trust among all team members

Values/Ethics Competencies Identified by Interprofessional Education Collaborative: See Box 13-5

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Patient–Provider Barriers Barriers arise from issues in patient–provider

relationshipExamples of barriers:

Cultural diversity Patient lacking an advance directive Patient non-adherence

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Strategies to Overcome Patient–Provider Barriers

Strategies: Change the goals of care in accordance with

patient’s and family’s perspectiveIn primary care, encourage conversations

about advance directivesSeek additional support from other resource

people

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Organizational/Environmental BarriersBarriers:

Lack of support Time constraintsLack of continuity of careLimited resources

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Strategies to Overcome Organizational/Environmental Barriers

Strategies: Identify internal and external resourcesKnow patient as personHelp achieve quality patient outcomes at

reduced cost to systemTrack outcomes for data to support system

change

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Ethics ResourcesSee Box 13-6

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ConclusionAs a core competency for APNs, ethical

decision making reflects both the art and science of nursing

APN in key position to: Assume more decisive role in managing

resolution of moral issues Create ethically responsive health care

environments

Chapter 13 Ethical Decision Making Dr Waddah D’emeh Dr. Waddah D'emeh.

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