🩹Professionalism and Research in Nursing Unit 2 – Ethical Decision-Making in Nursing

Key Concepts and Principles

• Autonomy involves respecting a patient's right to make their own informed decisions about their healthcare
• Beneficence requires nurses to act in the best interest of their patients and promote their well-being
  • Includes providing safe, competent, and compassionate care
• Non-maleficence obligates nurses to avoid causing harm to patients
  • Encompasses both intentional and unintentional harm
• Justice ensures fair and equitable treatment of all patients, regardless of their background or circumstances
• Veracity emphasizes the importance of honesty and truthfulness in the nurse-patient relationship
  • Includes providing accurate information and maintaining patient confidentiality
• Fidelity involves being faithful to one's commitments and responsibilities as a nurse
• Accountability holds nurses responsible for their actions and decisions in the course of their practice

Ethical Frameworks in Nursing

• Deontology focuses on the inherent rightness or wrongness of actions based on moral rules and duties
  • Emphasizes following universal principles regardless of consequences (categorical imperative)
• Utilitarianism seeks to maximize overall happiness and well-being for the greatest number of people
  • Considers the consequences of actions in determining their moral worth
• Virtue ethics emphasizes the importance of character traits and moral virtues in guiding ethical behavior
  • Includes qualities such as compassion, integrity, and courage
• Care ethics prioritizes the importance of relationships, empathy, and contextual understanding in moral decision-making
• Principlism incorporates four key principles: autonomy, beneficence, non-maleficence, and justice
  • Provides a framework for balancing and prioritizing these principles in specific situations
• Casuistry involves reasoning based on paradigm cases and analogies to guide decision-making in novel situations

Common Ethical Dilemmas

• End-of-life care decisions, such as withholding or withdrawing life-sustaining treatments
  • Balancing patient autonomy with quality of life considerations
• Allocation of scarce resources, such as prioritizing patients during a pandemic or disaster
• Confidentiality and privacy concerns, particularly when patient safety or public health is at risk
  • Determining when it is justifiable to breach confidentiality
• Informed consent and capacity issues, especially in cases of cognitive impairment or mental illness
• Conflicts between patient autonomy and professional judgment or standard of care
  • Navigating situations where a patient refuses recommended treatment
• Moral distress arising from institutional constraints or conflicting obligations
• Addressing healthcare disparities and ensuring equitable access to care

Decision-Making Models

• MORAL model: Massage the dilemma, Outline options, Review criteria and resolve, Affirm position and act, Look back
  • Provides a structured approach to analyzing and resolving ethical dilemmas
• 4-box method: Medical indications, Patient preferences, Quality of life, Contextual features
  • Organizes relevant considerations into four key categories to guide decision-making
• DECIDE model: Define the problem, Ethical review, Consider options, Investigate outcomes, Decide on action, Evaluate results
• Jonsen's 4-quadrant approach: Medical indications, Patient preferences, Quality of life, Contextual features
  • Similar to the 4-box method, but with a greater emphasis on the clinical context
• Kidder's ethical checkpoints: Recognize the dilemma, Determine the actor, Gather the facts, Test for right-versus-wrong, Test for right-versus-right, Apply ethical principles, Make a decision
• Realm-Individual Process-Situation (RIPS) model: Realm, Individual process, Situation
  • Considers the broader societal, individual, and situational factors influencing ethical decision-making

Legal and Professional Considerations

• Nurses must adhere to professional codes of ethics, such as the ANA Code of Ethics for Nurses
  • Provides guidance on ethical responsibilities and standards of practice
• State Nurse Practice Acts regulate the scope of nursing practice and establish disciplinary procedures for violations
• Federal and state laws govern various aspects of healthcare, including patient rights, informed consent, and confidentiality (HIPAA)
• Institutional policies and procedures may further specify ethical obligations and decision-making processes
  • Nurses should familiarize themselves with their organization's ethics committees and resources
• Documentation and reporting requirements ensure accountability and transparency in the decision-making process
• Collaboration with other healthcare professionals, such as physicians and social workers, is essential for comprehensive ethical deliberation
• Ongoing education and training in healthcare ethics is necessary to maintain competence and stay current with evolving issues

Case Studies and Real-World Applications

• Terri Schiavo case: Dispute over the removal of life support for a patient in a persistent vegetative state
  • Highlighted conflicts between patient autonomy, surrogate decision-making, and the role of the courts
• Tuskegee Syphilis Study: Unethical research involving the withholding of treatment from African American men with syphilis
  • Demonstrated the importance of informed consent, respect for persons, and the need for ethical oversight in research
• Dax Cowart case: Patient with severe burns who repeatedly requested to discontinue treatment and be allowed to die
  • Raised questions about the limits of patient autonomy and the duty to relieve suffering
• Baby Doe cases: Controversies surrounding the withholding of treatment from infants born with disabilities
  • Sparked debates about quality of life, disability rights, and the role of parental decision-making
• Henrietta Lacks case: Unauthorized use of a patient's cells for research without consent or compensation
  • Highlighted issues of informed consent, privacy, and the exploitation of vulnerable populations in research
• COVID-19 pandemic: Ethical challenges related to resource allocation, triage protocols, and vaccine distribution
  • Underscored the importance of fairness, transparency, and public trust in healthcare decision-making

Reflection and Self-Assessment

• Regular self-reflection is essential for identifying and examining one's own values, biases, and moral intuitions
  • Journaling, discussing with colleagues, and seeking feedback can facilitate this process
• Engaging in case-based discussions and debriefing sessions can help nurses develop their ethical reasoning skills
• Seeking mentorship from experienced nurses or ethics consultants can provide guidance and support in navigating complex issues
• Participating in interprofessional ethics rounds or committees can broaden one's perspective and foster collaborative problem-solving
• Assessing one's own moral distress and burnout is crucial for maintaining personal well-being and preventing compassion fatigue
  • Developing self-care strategies and seeking support when needed is essential
• Continuing education in healthcare ethics, through courses, workshops, or conferences, can deepen one's understanding and skills
• Engaging in research or quality improvement projects related to ethical issues can contribute to evidence-based practice and policy development

Resources and Further Reading

• American Nurses Association (ANA) Code of Ethics for Nurses
  • Provides a framework for ethical decision-making and standards of professional practice
• National Nurses Advocacy Center (NNAC)
  • Offers resources, education, and support for nurses facing ethical challenges in their practice
• American Society for Bioethics and Humanities (ASBH)
  • Interdisciplinary organization dedicated to advancing the field of bioethics through education, research, and policy development
• Hastings Center
  • Independent bioethics research institute that produces publications, resources, and policy recommendations on a wide range of ethical issues in healthcare
• Kennedy Institute of Ethics at Georgetown University
  • Academic center that offers courses, programs, and resources in bioethics and health policy
• "Principles of Biomedical Ethics" by Tom L. Beauchamp and James F. Childress
  • Seminal text that outlines the four principles approach to biomedical ethics
• "Nursing Ethics: Across the Curriculum and Into Practice" by Janie B. Butts and Karen L. Rich
  • Comprehensive textbook that explores ethical issues across various areas of nursing practice and education