Jimmy Banda, a 62-year-old homeless Indigenous
man, is being discharged into the community, but requires
supervision and support as well as ongoing healthcare. In
Chapter 5 the ethical dimension related to continuity of care
in the healthcare system was introduced. Consider Jimmy
Banda’s situation and reflect on the following questions. Is
healthcare a market commodity to which Mr Banda has
limited access due to lack of financial resources? Is health-
care a social right that should be freely available to all?
Now that you have reflected on the broad ethical
dimension, reflect further on your own and the profes-
sions values. Consider the situation from a nursing
ethics perspective. What are the moral obligations
of the case manager caring for Mr Banda?
Nurse ethicists frequently use two popular theoretical and
practical approaches to ‘doing ethics’—the
principle-based
approach
and the
care-based approach
. The principle-based
approach concentrates on the abstract concepts of ethical
principles from a more detached perspective, while the care-
based approach favours emotional involvement in a moral
or ethical dilemma in order to highlight the consequences of
nursing actions. Midwives who practise woman-centred care
may also use a
feminist approach
.
Principle-based approach
Beauchamp and Childress’ (2009) influential
principle-based
approach
to bioethics is based on a common morality. The
common morality is a set of norms shared by all persons
committed to morality. The authors identify four key princi-
ples:
autonomy
,
non-maleficence
,
beneficence
and
justice
Unit II Foundations of nursing and midwifery practice
198
(Table 11-1). Many nurses and midwives add
fidelity
, verac-
ity, accountability, privacy and confidentiality to this list,
because they play a central role in the tradition of nursing
(and medical) ethics, and guide the behaviour of healthcare
professionals towards patients and their families.
Principles offer general guides to action. All things being
equal, we ought to act at all times in a manner that respects
the autonomy of others, does not harm, does benefit others,
treats others fairly and is faithful to the promises we make
to others. Rarely is this as simple as it sounds. Be sensitive
to the fact that each individual (patients, family members
and professional carers) may identify benefits and harms
differently. A benefit to one may be a burden to another.
Ethical dilemmas
arise when attempted adherence to
basic ethical principles results in two conflicting courses of
action. There is no foolproof method for identifying which
principle is most important when there is conflict between
competing principles. Moral principles are most beneficial
to ethical decision in situations when there is disagreement
on a course of action. This is the very time that principles
can be relied on to find the best approach for the situation.
However, it is important to understand that nurses rarely
rely on a single principle to address an ethical dilemma.
Principles can be used in combination and ethical frame-
works or decision-making models are often utilised to guide
nursing practice in daily clinical situations.
Care-based approach
Dissatisfaction with the principle-based approach to
bioethics led many nurses to look to the provision of care and
caring as the foundation for nursing’s ethical obligations.
TABLE 11-1 Principles of bioethics
Principle
Moral rule
Implications for practice
Autonomy
Respect the rights of people
Provide the information and support patient and families
(self-determination) or their surrogates to make
need to make the decision that is right for them; at times, this
healthcare decisions.
may mean collaborating with other members of the health-
care team to advocate for the person.
Non-maleficence Avoid causing harm.
Seek not to inflict harm; seek to prevent harm or risk of harm
whenever possible.
Beneficence
Benefit the person, and balance
Commit yourself to actively promoting the person’s benefit
benefits against risks and harms. (health and well-being). Be sensitive to the fact that individuals
(patients, family members and professional carers) may
identify benefits and harms differently. A benefit to one may
be a burden to another.
Justice
Give each their due; act fairly.
Always seek to distribute the benefits, risks and costs of
nursing care justly. This may involve recognising subtle
instances of bias and discrimination.
Fidelity
Keep promises.
Be faithful to the promise you made to the public to be com-
petent and to be willing to use your competence to benefit the
people entrusted to your care. Never abandon a person
entrusted to your care without first providing for their needs.
