Cost-effectiveness and allocation
The increasing awareness of how difficult it is to make
valued and scarce health resources available to all in need
has resulted in new appreciation for the moral relevance of
cost-effectiveness. Nurses and midwives who are committed
to patient advocacy bridge the sometimes overwhelming
needs of patients and their families and the limited resources
available to professional carers. Justice is the principle of
bioethics that speaks to distributing the benefits and burdens
of healthcare delivery fairly. Nurses and midwives are
uniquely positioned within the interdisciplinary team to
speak to what it means to give people ‘their due’.
Issues of cultural and/or religious variation
Since many conflicts about what ought to be done are
rooted in different cultural or religious beliefs and values,
nurses and midwives who are sensitive to the cultural
and/or religious identity of patients and carers can help
mediate these conflicts.
Considerations of power
Differences in power underlie many of the ethical challenges
encountered in clinical practice. Injury and illness create vul-
nerabilities in the most sophisticated healthcare consumer and
mandate vigilance on the part of the nurse and other carers to
challenge any abuses of power by clinicians. Clinicians who
believe they lack power to influence care settings and deliv-
ery may also experience ethical conflict and distress.
Final note about trustworthiness
Common to all of the standards discussed above is the
obligation for nurses and midwives to be competent and
willing to use their competence to secure the health and
well-being or good dying of the person. When nurses or
midwives become aware that something is interfering with
people getting the care they need, they are responsible for
responding within the scope of their power and responsi-
bility. If they cannot independently resolve the problem,
they are responsible for alerting the appropriate party, who
may be the attending doctor, a nursing supervisor or a
medical director. While some believe ‘the problem is out
of their hands’ once they notify the next person in the chain
of command, ethically, the problem does in fact remain
theirs until appropriate action is taken. Thus, you should
know and use the chain of command, and continue to refer
a problem upwards until it is resolved and the person’s
needs are met.
Examples of ethical problems
Ethical problems commonly arise for nurses and midwives
between nurses and patients, midwives and women, nurses
and doctors, midwives and obstetricians, nurses and other
nurses, and nurses, midwives and their employing institu-
tions. Moreover, nurses and midwives are often most
Unit II Foundations of nursing and midwifery practice
206
conflicted when good practice seems to require acting
against their personal moral convictions. It is at this point
that the concept of
moral distress
can arise. Moral distress
is increasingly recognised within clinical practice as a situ-
ation that occurs when one is aware of the correct action but
is constrained in this action by other factors. Examples are
witnessing incompetent practices, judgemental behaviour
towards patients and families, witnessing unnecessary suf-
fering, and compromised care due to understaffing and other
system failures. Moral distress has the potential to cause
residual impact on nursing staff, who feel disempowered to
individually change the situation. Varcoe et al. (2012)
suggest that moral distress is a potentially useful concept in
which resolution can provide an opportunity for reflection
and growth in ethical practice (see Research in practice:
Moral distress and clash of personal values).
As you read through the following minicases, try to
determine how you would respond. The process of ethical
decision making described above should prove helpful.
Clinicians and patients
Troublesome clinician–patient situations that can result in
ethical problems for nurses include
paternalism
(acting for
patients without their consent to secure good or prevent
harm), deception, confidentiality, allocation of scarce
nursing resources, informed consent, and conflicts between
the patient’s and clinician’s values and interests.
Paternalism
An alert older resident who lives in a nursing home and who
is now at high risk for falls refuses to call the nurse for assis-
tance when getting out of bed. The nurse must decide whether
to obtain an order to restrain the resident. Does preventing
potential harm justify violating the resident’s right to auton-
omy, and make it acceptable for the nurse to act as a ‘parent’
and choose an action the resident does not want because the
nurse believes it to be in the resident’s best interest?
Deception
A postoperative patient asks the student nurse, who is about
to administer an intramuscular injection for pain, ‘Is this
your first injection?’ It does happen to be the student’s first
injection and the student is anxious. Would the student’s
intent to decrease the person’s anxiety justify telling the
them, ‘No, I’ve given several before’?
Confidentiality
A 9-year-old child confides in you that her father touches her
in her private area and she doesn’t like it. She doesn’t want
you to tell anyone. What is the ethical dilemma here and how
would you explain your subsequent actions to the child?
Allocation of scarce health resources
A nurse has just been pulled from your unit, leaving it
understaffed. Among your patients is a 33-year-old man
recovering from a heart attack who is being discharged in
the morning (he tells you he still has many questions); an
