20
Unit 1
Contemporary concepts in nursing
situations may result in
moral distress
,
through experiencing
an
ethical dilemma
in which the nurse is aware of the correct
course of action but institutional constraints stand in the way
of pursuing that action.
The moral dilemmas a nurse may encounter in the medical-
surgical arena are numerous and diverse. An awareness of
underlying ethical concepts will help the nurse to reason
through these dilemmas. Basic concepts related to moral
philosophy, such as ethics terminology, theories, and
approaches, are included in this chapter. The nurse should be
an advocate for patient rights in each situation (Johnstone,
2009). Understanding the role of the professional nurse
in ethical decision making will assist nurses in articulating
their ethical positions and in developing the skills needed
to make ethical decisions.
Ethics theories
One classic theory in ethics is
teleological theory or conse-
quentialism
, which focuses on the ends or consequences of
actions (Noureddine, 2001). The most well-known form of this
theory,
utilitarianism
, is based on the concept of ‘the greatest
good for the greatest number.’ The choice of action is clear
under this theory because the action that maximises good over
bad is the correct one. The theory poses difficulty when one
must judge intrinsic values and determine whose good is the
greatest. Additionally, the question must be asked whether
good consequences can justify any amoral actions that might
be used to achieve them.
Another theory in ethics is the
deontological or formal-
ist theory
, which argues that moral standards or principles
exist independently of the ends or consequences. In a given
situation, one or more moral principles may apply. The nurse
has a duty to act based on the one relevant principle, or the
most relevant of several moral principles. Problems arise when
personal and cultural biases influence the choice of the most
primary moral principle.
Approaches to ethics
Two approaches to ethics are ‘metaethics’ and ‘applied ethics’.
An example of metaethics (understanding the concepts and
linguistic terminology used in ethics) in the healthcare
environment would be analysis of the concept of informed
or valid consent (informed consent). Nurses are aware that
patients must give consent before surgery, but sometimes a
question arises as to whether the patient is truly informed.
Delving more deeply into the concept of informed consent
would be a metaethical inquiry.
Applied ethics is the term used when questions are asked
of a specific discipline to identify ethical problems within that
discipline’s practice. Various disciplines use the frameworks
of general ethical theories and moral principles and apply
them to specific problems within their domain. Common
ethical principles that apply in nursing include autonomy,
beneficence, confidentiality, double effect, fidelity, justice,
non-maleficence, paternalism, respect for people, sanctity of
life, and veracity. Brief definitions of these important princi-
ples can be found in Chart 2-2.
Nursing ethics may be considered a form of applied ethics
because it addresses moral situations that are specific to the
nursing profession and patient care. Some ethical problems
that affect nursing may also apply to the broader area of bio-
ethics and healthcare ethics. However, the nursing profession
is traditionally viewed as a ‘caring’ rather than a predominantly
‘curing’ profession; therefore, it is imperative that one not
equate nursing ethics solely with medical ethics, because the
medical profession has a ‘cure’ focus.
Types of ethical problems in nursing
As a profession, nursing is accountable to society. This
accountability is spelled out by the Australian Council on
Healthcare Standards (ACHS, 2012), which stipulates that
patients receive and understand information on their rights
and responsibilities for any healthcare services they may
receive. Nursing has also defined its standards of account-
ability in a formal code of ethics that explicitly states the
profession’s values and goals (Chart 2-3). The code is a
framework for nurses to use in ethical decision making, and
the value statements provide guidance to address and resolve
ethical dilemmas. New Zealand also has a code of conduct for
nurses and midwives consisting of ethical principles, each with
its explicit criteria. Efforts to enact this standard may cause
conflict in healthcare settings in which the traditional roles
of the nurse are delineated within a bureaucratic structure.
If, however, nurses learn to present ethical conflicts within
a logical, systematic framework, struggles over jurisdictional
boundaries may decrease.
Although technological advances and diminished resources
have been instrumental in raising numerous ethical questions
and controversies, including life-and-death issues, nurses
should not ignore the many routine situations that involve
ethical considerations. Some of the most common issues faced
by nurses today include confidentiality, use of restraints, trust,
end-of-life concerns, issues of pain control, resuscitation, life
support and removal of sustenance.
Confidentiality
The principle of confidentiality pertains to all forms of commu-
nication whether it be written, oral or electronic. Information,
often of a personal nature, is constantly obtained in daily
practice and if this information is not pertinent to a case, it
should not be recorded in the patient’s healthcare record. When
discussion of the patient with other members of the healthcare
team is necessary, it should occur in a private area where it is
unlikely that the conversation will be overheard. The wide-
spread use of electronic information in clinical practice requires
special emphasis. The disclosure of sensitive information such as
genetic testing or pathology results may lead to loss of employ-
ment or insurance if the information is misused. Adherence
to the principle of confidentiality is essential because of these
possibilities of maleficence (Chart 2-2) to the patient.
Restraints
The use of restraints (including physical and pharmacological
measures) is another issue with ethical overtones. It is import-
ant to weigh carefully the risks of limiting a person’s autonomy
and increasing the risk of injury by using restraints against the
risks of not using restraints. Other strategies, such as asking
family members to sit with the patient, have been shown to be
effective alternatives to restraints (Randle, 2013). Each state
has specific policies and the inappropriate use of restraint can
lead to an action of false imprisonment.
Trust issues
Two dilemmas in clinical practice that can directly conflict
with ethical principles are the use of placebos (non-active
