Ethical theories NURSING ETHICS

Ethical TheoriesEthical Theories

PIR BUXPIR BUX

25-08-201425-08-2014

ObjectivesObjectives

Discuss ethical principles in health care in the light of ethical theories.

2. Discuss the ethical dilemmas face by nurses and client.

3. Discuss the strategies to resolve ethical dilemma in daily nursing practice.

4. List steps of ethical decision-making

ETHICSETHICS

ACTION

INTENTION UTILITY

Philosophy BasisPhilosophy Basis

Two plus two make four, regardless of Two plus two make four, regardless of time, circumstances, feelings, belief time, circumstances, feelings, belief involved in the circumstancesinvolved in the circumstances

Killing Euthanasia AbortionKilling Euthanasia Abortion Killing during warKilling during war Reasonable argumentsReasonable arguments Ethical rules are less clear, difficult or Ethical rules are less clear, difficult or

impossible to prove impossible to prove

SoSo

Ethics is a systematic approach to Ethics is a systematic approach to understanding, analyzing, and understanding, analyzing, and distinguishing matters of right and wrong, distinguishing matters of right and wrong, good or bad, admirable or adorable as good or bad, admirable or adorable as they exist along the continuumthey exist along the continuum

WhyWhy

Scientific and technological advancesScientific and technological advances Economic realitiesEconomic realities Pluralistic worldviewsPluralistic worldviews Global communicationGlobal communication Develop an appreciation on personal Develop an appreciation on personal

philosophiesphilosophies Personal opinions, unexamined beliefs, Personal opinions, unexamined beliefs,

intuition or scientific reasoning intuition or scientific reasoning

ReasoningReasoning

It involves using abstract thought process It involves using abstract thought process to solve problems and formulate plans. to solve problems and formulate plans. (Angeles, 1992)(Angeles, 1992)

Ethical Theory: it Helps to provide Ethical Theory: it Helps to provide guidance in moral thinking and reasoning guidance in moral thinking and reasoning and justification for moral actions.and justification for moral actions.

Helps to discern common place morality Helps to discern common place morality and strengthen moral judgments in the and strengthen moral judgments in the face of moral dilemmas (Mappes 2001) face of moral dilemmas (Mappes 2001)

PhilosophyPhilosophy It is intense and critical examination of It is intense and critical examination of

beliefs and assumptions.beliefs and assumptions. Natural and necessary to humanityNatural and necessary to humanity Gives coherence to the whole realm of Gives coherence to the whole realm of

thought and experiencethought and experience Offers principles for deciding what actions Offers principles for deciding what actions

and qualities are most worth whileand qualities are most worth while May show inconsistency in meaning and May show inconsistency in meaning and

context (Kneller, 1971) context (Kneller, 1971)

PhilosophyPhilosophy It gives shape to what would otherwise be It gives shape to what would otherwise be

a random chaos other thoughts, beliefs, a random chaos other thoughts, beliefs, assumptions, values and superstitions.assumptions, values and superstitions.

Examines questions that deal with the Examines questions that deal with the most important aspect of lifemost important aspect of life

How can one find path that leads to end of How can one find path that leads to end of suffering? Buddasuffering? Budda

What is remedy for social disorderWhat is remedy for social disorder How should one liveHow should one live

Theory of ethicsTheory of ethics

Moral philosophy is the branch of Moral philosophy is the branch of philosophy that examines beliefs and philosophy that examines beliefs and assumptions about the nature of certain assumptions about the nature of certain human valueshuman values

Practical applicationPractical application Philosophy reveals an integrated vision in Philosophy reveals an integrated vision in

which elements, like pieces of puzzle, which elements, like pieces of puzzle, have a logical fithave a logical fit

NaturalismNaturalism Moral judgment that regards ethics as Moral judgment that regards ethics as

dependent on human nature and psychologydependent on human nature and psychology Attributes differences in moral codes to Attributes differences in moral codes to

social conditionssocial conditions All peoples have similar psychological All peoples have similar psychological

tendency (Raphael, 1994)tendency (Raphael, 1994) Universality or near universality in moral Universality or near universality in moral

judgmentjudgment Feelings about particular action in particular Feelings about particular action in particular

situationssituations

NaturalismNaturalism to make similar ethical decisions, value to make similar ethical decisions, value

differences among cultures,differences among cultures, Does not explain selfish, cruel choicesDoes not explain selfish, cruel choices Experience pleasure and avoid painExperience pleasure and avoid pain To be happy is to get pleasure and avoid To be happy is to get pleasure and avoid

painpain A natural tendency to sympathizesA natural tendency to sympathizes Helping people in need Helping people in need

SympathySympathy A motivating factor, is the sharing, in A motivating factor, is the sharing, in

imagination of others’ feelings. imagination of others’ feelings. Involves as pleasure, the tendency to Involves as pleasure, the tendency to

warm towards others who has pleased warm towards others who has pleased another, painanother, pain

The tendency to feel hostile toward one The tendency to feel hostile toward one who has caused pain to anotherwho has caused pain to another

It is a natural tendency and a basis for It is a natural tendency and a basis for moral reasoning moral reasoning

UTILITARIANISMUTILITARIANISM Jeremy Bentham (1748-1832)Jeremy Bentham (1748-1832) Consequential: teleologicalConsequential: teleological Telos Greek word meaning “end”Telos Greek word meaning “end” Action related to good or bad Action related to good or bad

consequences, result derived from itconsequences, result derived from it Naturalism: right action with greatest utilityNaturalism: right action with greatest utility Utility or usefulnessUtility or usefulness Actions are right when they increase Actions are right when they increase

happiness, and diminish miseryhappiness, and diminish misery wrong, when they have opposite effectwrong, when they have opposite effect

Principle of utilityPrinciple of utility Humans are sentient beingHumans are sentient being Good bad sensation (Epicurus)Good bad sensation (Epicurus) Hedonistic point of viewHedonistic point of view Six criteriaSix criteria Intensity, duration, certaintyIntensity, duration, certainty Propinquity: nearness in place or timePropinquity: nearness in place or time Fecundity : chances of it being followed by Fecundity : chances of it being followed by

sensation of same kindsensation of same kind Purity: chances of it not being followed by Purity: chances of it not being followed by

sensation of same kindsensation of same kind

RebirthRebirth ““end justifies means”end justifies means” ( John S Mill) ( John S Mill) “ “ action is conduct not agent’s own happiness”action is conduct not agent’s own happiness” Object of happiness is multiplicationObject of happiness is multiplication It is beyond physical pleasureIt is beyond physical pleasure It could be gift, profit, benefit so on…..It could be gift, profit, benefit so on….. A type of action which augment A type of action which augment Happiness of Happiness of

community as a wholecommunity as a whole Life of moderation, courage, justiceLife of moderation, courage, justice Cultivating friendship Cultivating friendship

RATIONALISM:RATIONALISM: feelings and perceptions seems similar, feelings and perceptions seems similar,

are not actually or may not be sameare not actually or may not be same Absolute truths that are not dependent on Absolute truths that are not dependent on

human naturehuman nature ethical value have an independent origin, ethical value have an independent origin, in the universe or from of Godin the universe or from of God Known through reasoning processKnown through reasoning process Truth about the world that is necessary Truth about the world that is necessary

and universe, are superior than the and universe, are superior than the information, we receive from our sensesinformation, we receive from our senses

Misfortune, feel bad for self or one, but not Misfortune, feel bad for self or one, but not for allfor all

Ethics variations being free of human Ethics variations being free of human nature or matter of reasoning nature or matter of reasoning

““Help others” maxim shouldn’t change bcs Help others” maxim shouldn’t change bcs of feelings or circumstancesof feelings or circumstances

Origin……..feelings ………. ReasonsOrigin……..feelings ………. Reasons Foundation predictable human natureFoundation predictable human nature universal or theological truthuniversal or theological truth

DeontologyDeontology Deontology: Greek word DutyDeontology: Greek word Duty Formalism/ Kantianism (Immanuel Kant)Formalism/ Kantianism (Immanuel Kant) Nature of the act rather than Nature of the act rather than

consequencesconsequences Shook religious and political systemShook religious and political system Ethical rules are universal,Ethical rules are universal, Awareness of moral rule is product Awareness of moral rule is product

reason, not experiencereason, not experience absolute and apply to all peoplesabsolute and apply to all peoples Knowledge could be obtained by a maximKnowledge could be obtained by a maxim

A person is a rational human being with A person is a rational human being with freedom, moral worth, and ideally a good freedom, moral worth, and ideally a good will will meaning a person should act from a meaning a person should act from a sense of duty.sense of duty.

Humans have freedom to make moral Humans have freedom to make moral judgmentsjudgments

Human should drive certain rules to guideHuman should drive certain rules to guide Peoples ought to follow a universal Peoples ought to follow a universal

framework of moral maxim or rules to framework of moral maxim or rules to guide right actions guide right actions

Categorical ImperativeCategorical Imperative Categorical: Moral rules that do not admit Categorical: Moral rules that do not admit

exceptionsexceptions Imperative: Command that is derived from principleImperative: Command that is derived from principle

“ “ Act only according to that maxim by Act only according to that maxim by which you can at the same time will that it which you can at the same time will that it should become a universal law” should become a universal law” (Trans. 1959(Trans. 1959

A categorical has always a meaningA categorical has always a meaning Morally right actions are universal lawMorally right actions are universal law Treat person as end not only as meanTreat person as end not only as mean Equal and rationalEqual and rational

Regard of others desires, allow them Regard of others desires, allow them choicechoice

Liberty, equality, fraternity in politically Liberty, equality, fraternity in politically organized societyorganized society

Treat all people as ends, not as means to Treat all people as ends, not as means to an endan end

Codes of Ethics: importance of fulfilling Codes of Ethics: importance of fulfilling duties that are ownedduties that are owned

Dignity and autonomyDignity and autonomy Dilemma: Conflicting values, rigid, Dilemma: Conflicting values, rigid,

exception less, exception less,

Practical ImperativesPractical Imperatives Act so that you treat humanity, whether in Act so that you treat humanity, whether in

your own person, or that of another, your own person, or that of another, always an end and never a means to an always an end and never a means to an end only. (trans. 1959)end only. (trans. 1959)

Domination of one person over another is Domination of one person over another is morally wrong. morally wrong.

No allowance for dominated person’s No allowance for dominated person’s power of decision makingpower of decision making

Realms of ends– politically organized Realms of ends– politically organized societysociety

A systematic union of rational beings A systematic union of rational beings through common objective lawthrough common objective law

Equal and autonomous members Equal and autonomous members Promote regards for others wishes, Promote regards for others wishes,

desiresdesires Allow them freedom of decision makingAllow them freedom of decision making Ethics of democracyEthics of democracy It requires liberty, equality, fraternityIt requires liberty, equality, fraternity Moral worth based on reverence of law Moral worth based on reverence of law

ApplicationApplication Most codes of ethics are basedMost codes of ethics are based Importance of fulfilling your duties and Importance of fulfilling your duties and

obligations, inherently owed obligations, inherently owed Preserving the dignity and autonomyPreserving the dignity and autonomy “ “ The Nurse establishes relationship and The Nurse establishes relationship and

delivers nursing services with respect for delivers nursing services with respect for patients’ needs and values without patients’ needs and values without prejudicesprejudices

Should not go unnoticedShould not go unnoticed But is exception less, rigid and conflictingBut is exception less, rigid and conflicting

Hypothetical Imperatives Hypothetical Imperatives Duties or rules that people ought to Duties or rules that people ought to

observe if certain ends are to be achieved.observe if certain ends are to be achieved. ““If- then”If- then” ConditionalConditional ““If I want to pass exam, then I should be If I want to pass exam, then I should be

diligent in my studies”diligent in my studies” Moral actions must be unconditionalMoral actions must be unconditional Laws are absolute and universalLaws are absolute and universal If I perform this action, would I If I perform this action, would I willwill that it that it

becomes a universal law. becomes a universal law.

Virtue EthicsVirtue Ethics Virtue: excellence of intellect or characterVirtue: excellence of intellect or character Character: certain innate moral virtueCharacter: certain innate moral virtue What sort of person must I be to achieve What sort of person must I be to achieve

my life purposesmy life purposes What makes one a good or excellent What makes one a good or excellent

personperson Rather than “what is right or good to be Rather than “what is right or good to be

based on my duty or to achieve good based on my duty or to achieve good consequencesconsequences

Virtues are intellectual or character traits Virtues are intellectual or character traits or habits that are developed throughout or habits that are developed throughout one’s lifeone’s life

Personal effort, training, and practice Personal effort, training, and practice Cardinal Virtues: Wisdom, courage, hope Cardinal Virtues: Wisdom, courage, hope

justice, faith, love, charity, temperance, justice, faith, love, charity, temperance, Honesty, compassion, caring, Honesty, compassion, caring,

responsibility, integrity, discernment, responsibility, integrity, discernment, trustworthiness, prudencetrustworthiness, prudence

Nursing: an important framework for Nursing: an important framework for examining moral behavior examining moral behavior

“ “ What morally we ought to do?”What morally we ought to do?” It is not moral requirement?It is not moral requirement? Moral virtue is a character trait that is Moral virtue is a character trait that is

morally valuedmorally valued A person with moral virtue has both A person with moral virtue has both

consistent moral action and morally consistent moral action and morally appropriate desireappropriate desire

Practice of virtuous behaviorPractice of virtuous behavior Rather than virtuous acts being the end Rather than virtuous acts being the end

result of good characterresult of good character

Virtues are tendencies to act, feel, and Virtues are tendencies to act, feel, and judge that are developed from nature judge that are developed from nature capacity by proper training and exercisecapacity by proper training and exercise

Practice creates habit of acting in a virtuous Practice creates habit of acting in a virtuous wayway

Virtue can be learned and improvedVirtue can be learned and improved Excellence of character depends on Excellence of character depends on

motivation, deliberation, clear judgment, self motivation, deliberation, clear judgment, self control and practice control and practice

Fruit of intelligent pursuit Fruit of intelligent pursuit Possession of the simple person, not the Possession of the simple person, not the

gift of innocent intent (Aristotle) gift of innocent intent (Aristotle)

Virtuous acts must be chosen for their own Virtuous acts must be chosen for their own sakesake

Virtuous character is created repeatedly Virtuous character is created repeatedly acting in a virtuous manneracting in a virtuous manner

Virtuous acts must be chosen for their own Virtuous acts must be chosen for their own sakesake

Choice must proceed from a firm and Choice must proceed from a firm and unchangeable characterunchangeable character

Virtue is disposition to choose the meanVirtue is disposition to choose the mean Human wellbeing is the highest aim of Human wellbeing is the highest aim of

moralitymorality

Golden mean of virtuous behavior Golden mean of virtuous behavior Golden Virtue: Practicing moderationGolden Virtue: Practicing moderation Avoiding both excess and deficiencyAvoiding both excess and deficiency No list of moral principlesNo list of moral principles Basic Moral question is not “What should one Basic Moral question is not “What should one

do?” but “What should one be?”do?” but “What should one be?” Virtue lies not only engaging in virtuous acts, but Virtue lies not only engaging in virtuous acts, but

also in also in Will ( Phillipa Foot)Will ( Phillipa Foot) Will Will is defined as “which is wished for as well as is defined as “which is wished for as well as

what is sought.” what is sought.” Positive will is sometimes the necessary Positive will is sometimes the necessary

ingredient in successingredient in success

Sometimes one man succeeds where Sometimes one man succeeds where another fails not because there is some another fails not because there is some specific difference in their previous specific difference in their previous conduct but rather because his heart lies conduct but rather because his heart lies in different place; and disposition of heart in different place; and disposition of heart is part of virtue. A man’s virtue is judged is part of virtue. A man’s virtue is judged by his inner most desires as well as by his by his inner most desires as well as by his intentions. This fits with idea that a virtue intentions. This fits with idea that a virtue such as generosity lies as much as such as generosity lies as much as someone’s attitudes as in his actions. someone’s attitudes as in his actions. ( Phillipa foot, 1997)( Phillipa foot, 1997)

According to footAccording to foot Virtue is not a skill or an artVirtue is not a skill or an art Can’t be merely a practiced or perfected Can’t be merely a practiced or perfected

actact It must engage in willIt must engage in will An act can’t be considered virtuous, if the An act can’t be considered virtuous, if the

intention is not goodintention is not good Virtue is one of hope (every one has Virtue is one of hope (every one has

capacity to learn virtuous acts butcapacity to learn virtuous acts but Road to virtuous character is less easily Road to virtuous character is less easily

traveled traveled

Nursing VirtuesNursing Virtues Character: As being made up of a set of Character: As being made up of a set of

stable traits that affect a person’s stable traits that affect a person’s judgment and actionjudgment and action

All persons have different character traits, All persons have different character traits, and all have capacity to learn and cultivate and all have capacity to learn and cultivate those that are important to morality those that are important to morality

Compassion: ability to imagine oneself in Compassion: ability to imagine oneself in the situation of another, or a trait of the situation of another, or a trait of combining an attitude of active regard for combining an attitude of active regard for another’s welfare, imaginative awareness another’s welfare, imaginative awareness and emotional response and emotional response

Deep sympathy and discomfort at the Deep sympathy and discomfort at the other person’s suffering.other person’s suffering.

Compassionate and caring presence Compassionate and caring presence outweigh need for technical careoutweigh need for technical care

But it does not impede ability to make But it does not impede ability to make objective decisionsobjective decisions

Discernment: wisdom, sensitive insights, Discernment: wisdom, sensitive insights, acute judgment, understanding, acute judgment, understanding, appropriate action in given situationsappropriate action in given situations

It results in decisive actionsIt results in decisive actions Requires sensitivity and attention Requires sensitivity and attention

Strives to recognize and understand Strives to recognize and understand important nuances in human behaviorimportant nuances in human behavior

Comfort and reassurance rather than Comfort and reassurance rather than privacyprivacy

Trustworthiness: confident belief in the Trustworthiness: confident belief in the moral character of another person,moral character of another person,

another person will act with the right another person will act with the right motives in accord with moral norms,motives in accord with moral norms,

consistency, predictability,consistency, predictability, Accounted for in the reputation we have Accounted for in the reputation we have

among coworkersamong coworkers

Helps in developing relationships Helps in developing relationships Integrity: soundness, reliability, wholeness, Integrity: soundness, reliability, wholeness,

and a coherent integrationand a coherent integration Continue over time, reasonable stable, Continue over time, reasonable stable,

justified in action and judgment, justified in action and judgment, A person of integrity has a consistency of A person of integrity has a consistency of

conventions, actions, emotions, and is conventions, actions, emotions, and is trustworthytrustworthy

Deficiency may include hypocrisy, Deficiency may include hypocrisy, insincerity, and bad faith insincerity, and bad faith

Virtue ethics in NursingVirtue ethics in Nursing One of aim of philosophy is to cultivate in One of aim of philosophy is to cultivate in

gifted people their potential intellectual and gifted people their potential intellectual and moral qualitiesmoral qualities

The nightingale pledge: Promise purity, The nightingale pledge: Promise purity, faith, love, loyalty, devotion, temperance faith, love, loyalty, devotion, temperance trustworthiness,trustworthiness,

Good character is cornerstone of good Good character is cornerstone of good nursingnursing

Nurse will act according to principle Nurse will act according to principle

Natural Law EthicsNatural Law Ethics Saint Thomas Aquinas (1225-1274)Saint Thomas Aquinas (1225-1274) Disseminated by Roman catholic churchDisseminated by Roman catholic church Also influenced by AristotleAlso influenced by Aristotle Rightness of an action is self evident from Rightness of an action is self evident from

the law of naturethe law of nature most cases Orchestrated by lawgiver Godmost cases Orchestrated by lawgiver God Morality is determined not by customs, Morality is determined not by customs,

and human preferences but is and human preferences but is commanded by law of reasoncommanded by law of reason

Implanted in nature and human intellectual Implanted in nature and human intellectual

Natural law ethicists believed that behavior Natural law ethicists believed that behavior that is contrary to their views of the laws of that is contrary to their views of the laws of nature is immoralnature is immoral

Examples are artificial means of birth control, Examples are artificial means of birth control, and homosexual relationships and homosexual relationships

Moral/ ethical ProblemsMoral/ ethical Problems

Moral Uncertainty: sense that a moral Moral Uncertainty: sense that a moral problem, but are not sure of morally problem, but are not sure of morally correct action, unable to define moral correct action, unable to define moral problem what moral theory/ principle problem what moral theory/ principle apply, sense something is not right, apply, sense something is not right, uncomfortable with the situationuncomfortable with the situation

Can’t figure out the problem Can’t figure out the problem Nature and cause of inadequacyNature and cause of inadequacy

Moral/Ethical DilemmaMoral/Ethical Dilemma

A dilemma exists when a difficult problem A dilemma exists when a difficult problem seem to have no satisfactory solution or seem to have no satisfactory solution or when all solutions to a problem appear when all solutions to a problem appear equally favorable (Davis 97)equally favorable (Davis 97)

Conflicting moral claimsConflicting moral claims Conflict = evidenceConflict = evidence Terminally ill patient, preserve life, prolong Terminally ill patient, preserve life, prolong

suffering suffering

Agent, one or more moral norms exists Agent, one or more moral norms exists Critical care bed allocation?Critical care bed allocation? Perceive or conceptualize: obligation, principle, Perceive or conceptualize: obligation, principle,

duties, rights, loyaltiesduties, rights, loyalties Moral Distress:- face situations seem to have Moral Distress:- face situations seem to have

clear solutions, yet unable to follow their moral clear solutions, yet unable to follow their moral belief due to restraintsbelief due to restraints

No conflicting moral claimsNo conflicting moral claims Impossible to peruse course of actionImpossible to peruse course of action Powerless, hierarchy, culture of silencePowerless, hierarchy, culture of silence Personal risky = hospitals end Personal risky = hospitals end

Moral OutrageMoral Outrage

Someone else performs an act the nurse Someone else performs an act the nurse believes to be immoralbelieves to be immoral

Do not participate directlyDo not participate directly No feelings of responsibility but No feelings of responsibility but

powerlessnesspowerlessness Whistle blowingWhistle blowing may be response to moral may be response to moral

outrageoutrage

REFERENCES: REFERENCES:

Burkhardt, M.A; Nathaniel, A.K. Ethics & Burkhardt, M.A; Nathaniel, A.K. Ethics & Issues: in Contemporary Nursing. (2Issues: in Contemporary Nursing. (2ndnd ed) . ed) . Delmar Thomson Learning Ch:2 (20-38), Delmar Thomson Learning Ch:2 (20-38), Ch:6 (92-96)Ch:6 (92-96)