Textbook of Medical-Surgical Nursing 3e

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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 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 primary moral principle. Approaches to ethics

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