 INTRODUCTION:

Ethical values are essential for any healthcare provider. Ethics comes from the Greek word “ethos,”
meaning character. Ethical values are universal rules of conduct that provide a practical basis for
identifying what kinds of actions, intentions, and motives are valued. Ethics are moral principles that
govern how the person or a group will behave or conduct themselves. The focus pertains to the right and
wrong of actions and encompasses the decision-making process of determining the ultimate consequences
of those actions. Each person has their own set of personal ethics and morals.
Ethics within healthcare are important because workers must recognize healthcare dilemmas, make good
judgments and decisions based on their values while keeping within the laws that govern them. To practice
competently with integrity, nurses, like all healthcare professionals, must have regulation and guidance
within the profession. The American Nurses Association (ANA) has developed the Code of Ethics for this
purpose. The Indian Nursing Council has also established standards of nursing practice for professional
nurses in India.

 NURSING ETHICS:

The term ‘ethic’ comes from Greek Word ‘ethikos’ which mean ‘moral’ or ‘character’.

Nursing ethics is the discipline devoted to the identification, analysis and resolution of value-based
problems that arise in the care of patients. The discipline is unique only because it relates to the particular
dilemmas that arise in medicine, not because it embodies or appeals to some special moral principles or
methodology. The practice of nursing ethics seeks to identify and resolve competing moral claims among
patients, their families, healthcare professionals, healthcare institutions, and society at large.

The terms morality and ethics are often used interchangeably, but most philosophers draw a distinction
between the two. Morality consists of social norms of behavior that often vary among cultures. The
discipline of ethics involves the development of philosophic reasons for or against a set of moral
judgments. Usually, the latter effort attempts to articulate and justify principles that form the foundation for
rules of conduct and decision making in the face of competing moral claims. Ethics are involved and
influenced by:

1. Laws
2. Religion
3. Scientific studies
4. Philosophy
5. Moral
 PRINCIPLES GOVERNING ETHICAL DECISIONS:
It is based on following 5 principles:
A. Non- maleficence:
This is based on Florence Nightingale’s first dictum ‘do no harm’. This idea is also found in Hippocrates
principle of ‘Prima noncore’ i.e. do not harm. This is designed to protect the patients as the Nurse is
bound to act with only positive benefit on the part of the patient.
However, a good effect should never be a result of wrong action. The non-maleficence principle is also
applied to the nurses and prevents ill treatment and behavior towards co-workers.
E.g- While performing Wound repair for a child, Nurse sutures the wound and restores skin integrity but
does not administer local anesthesia before doing the procedure. Though the outcome is good, but the
process is severely painful to the child.
 B. Beneficence:
It is the obligation of the nurse to advocate in interest of the patient’s health, right and must remove every
harm coming their way. The Nurse must invest time and effort to ensure patient’s benefit in every situation
with an attitude of ethical selflessness.
The difficulty with this principle lies in defining what is good for the patient due to difference in personal
opinions, cultural and ethnic diversity, etc. Thus, even if the nurse faces a contradictory situation, she must
always put patient’s need to the priority.
E.g: The nurse provides immediate wound care and does pain management to the patient in the Emergency
Room without even distinguishing the patient’s socio-economic background abiding by the principle of
selflessness.

C. Parental Autonomy:
Parental Autonomy means the parents have right or freedom to maintain control and taking full command
towards the treatment of the child. The parents have fundamental right to raise concern regarding all
decisions towards child’s health & welfare.
The practice of autonomy denies nurses the opportunity to persuade the parents to take a specific action or
treatment plan. This principle is vital for delivery of Evidence Based Practice. The Nurse should not
influence the Parent’s decision but must responsibly educate and inform the parents about the decision.
E.g: Parents of 5 years old are informed about the emergency Operation needed on the child due to Acute
Appendicitis but the parents refuse to give consent to surgery and imposing medical intervention for the
condition.

D. Correct medical facts:

Nurses should assist parents to make an informed decision based on available medical facts. The medical
reports should be unaltered and unmanipulated. It is the right of the parents to receive accurate medical
updates based on which they can plan the course of treatment in collaboration with the health team.
Nursing records also play a vital role. Without clear and accurate nursing records patient’s wellbeing will
be affected. It sets the standard of nursing care too.
E.g, Procedure of assessment of temperature in a child with fever in regular interval sets the dose and
frequency of provision of antipyretic drug. Nurse informs the mother whether the baby has fever or not,
nurse informs the mother correctly so that the mother provides sponge bath to the baby.

E. Justice:

Nurse must seek morally correct distribution of resources; ensure cost effectiveness of therapeutic measures
by balancing medical benefits & burdens to the family & society. Every child deserves advanced medical
services irrespective of their caste, religion, sex, socio-economic condition, etc. The top priority of all
nurses is saving lives and providing care.

E.g. Parents rushes in the emergency room with a child with convulsions. The nurse carries out emergency
interventions, stabilizes the child and moves to documentation to find out that the family is an unauthorized
immigrant. The nurse though informs the authority concerned but continues giving treatment to the child.
 F. Veracity:
Truth telling is a core principle that every professional nurse must follow. The is bound to tell truth even if
causes patient’s distress. She is bound to maintain a trusted relationship with the parents. As the nurse is
absolutely truthful about the child’s condition, it allows the parents to take thoughtful decisions regarding
the child’s course of treatment. The Truth telling earns the much-desired respect to the profession.
E.g: A child with terminal cancer is undergoing treatment. As the parents get to know from the nurse about
the condition of the child, they seek palliative home-based care.

 SOURCES OF MORAL GUIDANCE:

Everyone draws on multiple sources of moral guidance, including parental and family values, cultural
traditions, and religious beliefs. These sources are the roots of moral values, and they create a disposition to
do the right thing. However, for many reasons these values and beliefs do not provide sufficient guidance
for addressing dilemmas in clinical ethics.

o First, personal moral values might not address important issues in clinical ethics. Often nurses are
first confronted by difficult ethical issues during education or clinical practice. Personal moral
values might also offer conflicting advice on a particular situation; nurses may hold several
fundamental beliefs that are in conflict. A nurse may want to alleviate the suffering of a dying infant
while also respecting the sanctity of life. When nurses or other healthcare providers encounter a
dilemma in clinical ethics, it is not a reflection of character or background.

o The nurse’s personal values and beliefs may not be sufficient to guide a dilemma in clinical ethics,
because nurses have role-specific ethical obligations that go beyond their obligations as a good
person. Finally, to resolve ethical dilemmas in patient care, nurses need to persuade others of their
plan or recommendations, and this may require generating a consensus or compromise. Healthcare
workers, patients, and family members may have different religious or cultural backgrounds than
those of the patient. Clinical ethics analyze the reasons that justify a particular course of action.
People can be persuaded by cogent arguments, and people with different world views can reach
agreement in specific cases.

o Occasionally, individuals may explain their actions as a matter of conscience: to act otherwise
would make them feel guilty or ashamed or violate their sense of wholeness or integrity.
Conscience involves self-reflection and judgment about whether an action is right or wrong.
Conscience thus arises from a fundamental commitment or intention to be moral. It unites the
cognitive, conative, and emotional aspect of the moral life by a commitment to integrity or moral
wholeness. It is a commitment to uphold one’s deepest self-identifying moral beliefs; a commitment
to discern the moral features of a particular case as best one can, and to reason morally to the best of
one’s ability; a commitment to emotional balance in one’s moral decision-making; and a
commitment to make decisions according to one’s moral ability and to act upon what one discerns
to be the morally right course of action.

o In general, deeply held claims of conscience should be honored; it would strip persons of their
moral agency to compel them to act in ways that violate their sense of integrity and responsibility.
Claims of conscience, however, might not always resolve a dispute. Other people might cite their
own conscience as a countervailing argument. Occasionally, one can believe that an act is morally
wrong when it is actually permissible and vice versa.

o Individuals often appeal to rights, such as a right to healthcare, to explain positions on ethical
issues. To philosophers, rights are justified claims that a person can make on others or on society.
The language of rights is widespread, but an appeal to rights is often controversial. Other people
might deny that the right exists or assert conflicting rights. Claims of rights are often used to end
 debates; however, the crucial issue is whether persuasive arguments support the existence of the
right.
o Moral principles offer general values to guide us in making practical choices; several have become
important focal points for discussions in medical ethics. The principle of beneficence instructs the
promotion of people’s well-being and nonmaleficence—to avoid harming people. The principle of
distributing justice directs a fair allocation of goods, benefits, and services among those in a group,
whereas the principle of social utility guides the promotion of the greatest good for the greatest
number of people in a society. The principle of autonomy or self-determination prescribes that a
person act to foster personal responsibility and plan his or her life to develop abilities and
opportunities to flourish.

o It is a mistake to suppose that moral principles simply prescribe what to do or require uniform
action and conformity. First, because they are stated abstractly, they must be interpreted or
specified35; this is done by making practical moral judgments, leaving considerable room for
interpretation and disagreement from person to person or from culture to culture, even among those
who agree on the importance of these principles. Second, because principles can conflict in a given
situation, they sometimes have to be ranked, and people can reasonably disagree about how to do
this justifiably.

Nursing ethics then involve deliberation and explicit arguments to justify

particular actions in specific situations. Ethics focus on the reasons why an action is considered right or
wrong and asks individuals to justify their positions and beliefs by rational arguments that can persuade
others.

 CREATING SUPPORTIVE ENVIRONMENT FOR ETHICAL PRACTICE IN PICU:

On a daily basis nurses, physicians, and other members of the pediatric critical care healthcare team are
faced with maintaining the delicate balance between the application of complex technological care and
humane, ethical care for the critically ill pediatric patient.

o Ethical considerations in the pediatric critical care unit often involve moments of crisis marked by
disagreement over decisions, such as whether to resuscitate a patient; to withhold or withdraw
“futile” treatment over a patient’s or family’s objections; or to allocate limited or expensive
resources, such as extracorporeal membrane oxygenation or the last pediatric critical care unit bed.

o The expansion of technology combined with awareness of biologic, economic, and ethical limits to
applying that technology can lead to uncertainty and conflict when it appears that providers are
unable to restore a patient to the patient’s previous state. To address these complex issues, the
pediatric critical care unit team must recognize and address the ethical issues that exist each and
every day in interactions with families, patients, and fellow workers.

o The creation of an ethical working environment in the pediatric critical care unit is a necessary
precondition for addressing ethical issues involved in cardiopulmonary resuscitation, the limitation
or withdrawal of life-sustaining treatment, and conflicts in medical decision making.

o An ethical work environment fosters early identification of ethical dilemmas; provides resources for
ethical decision making; promotes open communication among all members of the healthcare team,
including patients and families; and promotes collaborative relationships. Without a supportive,
ethical environment, the healthcare system will likely cause moral distress, work dissatisfaction, and
a lack of collaboration that will undermine quality patient care.

The American Association of Critical Care Nurses has

recognized the inextricable links among quality of the work environment, excellent nursing practice, and
patient care outcomes. The American Association of Critical Care Nurses is also committed to creating
work and care environments that are safe, healing, humane, and respectful of the rights, responsibilities,
needs, and contributions of all people, including patients, their families, and nurses. Six standards for
establishing and sustaining healthy work environments have been identified:

Key Elements for Establishing and Sustaining Healthy Work Environments

• Skilled Communication—Nurses must be as proficient in communication skills as they are in clinical

skills.

• True Collaboration—Nurses must be relentless in pursuing and fostering true collaboration.

• Effective Decision Making—Nurses must be valued and committed partners in making policy, directing
and evaluating clinical care, and leading organizational operations.

• Appropriate Staffing—Staffing must ensure the effective match between patient needs and nurse
competencies.

• Meaningful Recognition—Nurses must be recognized and must recognize others for the value each
brings to the work of the organization.

• Authentic Leadership—Nurse leaders must fully embrace the imperative of a healthy work environment,
authentically live it and engage others in its achievement.

o Although the key elements are neither detailed nor exhaustive, they provide a foundation for
thoughtful reflection and engaged dialogue about the realities of each work environment. Because
of the interdependence of a healthy work environment, clinical excellence, and optimal patient
outcomes, adoption of these six key elements helps to optimize quality care and patient safety.
These six elements are also crucial steps to ensure solid reflection on ethical dilemmas present in
the pediatric critical care unit.

o A frequent ethical problem in the acute care setting is a difference of opinion among the healthcare
team and often involves disputes between and a nurse and a physician. Such conflicts typically
involve a nurse disagreeing with a physician concerning ethical issues such as the extent or
invasiveness of treatment, when to stop treatment, and when not to attempt resuscitation in the event
of a cardiac or respiratory arrest.

In order to create an environment that supports ethical practice,

a shift from a chain-of-command relationship to interdisciplinary care is required. An interdisciplinary
approach seeks to blur professional boundaries and requires trust, tolerance, and a willingness to share
responsibility. The challenge in the pediatric critical care unit is to develop and sustain organizational and
structural changes that reflect an ethical practice environment, making routine the collaborative and
communicative strategies that ethical issues often require.

 HOW ARE ETHICAL ISSUES IN PEDIATRICS DIFFERENT?

Children Are Different

o Children are smaller than adults. This fact is obvious, but the practical and ethical implications are
substantial. “The child’s small size can contribute to the child’s feeling intimidated by adults, even
if unintentionally. Adults must physically look down at children, and children unavoidably must
look up at adults. The world is largely designed for adults; so, although adults sit down, children
 must climb up. These simple physical facts both establish and illustrate the relative imbalance of
power, influence, and authority between children and adults.”

o The relatively greater dependence and relatively lower autonomy of children present complex
ethical challenges when clinical care is provided to children. Customary ethical principles of
autonomy and informed consent can be different in pediatric applications. Common ethical
principles such as beneficence and “do no harm” often are more multifaceted and less
straightforward. Treatment objectives expressed by parents or other child caretakers can be different
from the child’s goals.

Healthcare professionals are ethically compelled to respect and

integrate the child’s expressed wishes, the parents’ expressed outcomes, the child’s maturational needs, and
the family’s cultured beliefs about family roles and child-rearing practices. Such considerations bring new
ethical considerations and challenges to treatment.

Caring for Children: Core Ethical Issues

• Children are inherently more vulnerable than adults.

• Children’s abilities are more variable and change over time.

• Children are more reliant on others and their environment.

• Ethical principles and practices in the treatment of adults must be modified in response to the child’s
current developmental abilities and legal status.

• Healthcare professionals must develop skills to work with families, agencies, and systems.

• Healthcare professionals must maintain an absolute commitment to the safety and well-being of the child.

• Although young children are not autonomous, their potential autonomy deserves respect.

• The primary focus in decision making should be the interests of the child.

• Healthcare professionals must constantly monitor one’s own actions and motivations.

• Healthcare professionals must seek consultation and advice in difficult situations.

• Children should be given the protection of privacy.

• All persons with decisional capacity, regardless of age, have the right to make healthcare treatment
decisions.

Children are inherently more vulnerable than most adults.

Healthcare professionals have even more responsibility for ensuring ethical action than they would have
with adult patients. Nurses are in a unique position to identify situations in which parental decisions or a
child’s actions jeopardize a child’s health and well-being. Healthcare professionals are given special
responsibilities in these situations because if they do not intervene, children might suffer serious, long-
lasting harm.

o Because children cannot weigh risks and benefits, compare alternatives, or appreciate the long-term
consequences of decisions, they are incapable of making informed decisions. As a result, autonomy
is less important in pediatrics than in adult medicine. A child’s objections to beneficial medical
interventions do not have the same ethical force as an adult’s informed refusals. Because children
 are immature and vulnerable, they need an adult to make decisions for them and to protect their best
interests. Parents are presumed to be the appropriate decision makers.

o Children must be protected from the consequences of their own unwise decisions or those of others.
Indeed, it is tragic if a child dies or undergoes serious harm because a simple, effective medical
treatment was not provided.

o Although young children are not autonomous, their potential autonomy as future adults deserve
respect. Parents influence children and shape their behavior and values, and parental values deserve
great deference. However, when children reach maturity, they might choose values that differ from
those of their parents. Healthcare professionals may need to help ensure that parental decisions are
not contrary to those of the developing young adult.

o As children mature, they become capable of making informed decisions, and their involvement in
care should increase. Pediatric critical care unit professionals need to provide the child with
information about his or her condition and opportunities to participate in decisions about healthcare,
to the extent that it is developmentally appropriate.

o Children also differ from one another. In a very real way, there is no such category as “children.”
Infants differ from toddlers, who differ from preschoolers, who differ from school-aged children
and adolescents. Furthermore, within any group of children there is wide variability in size, ability,
psychosocial development, cognitive development, and maturity. Many children develop
inconsistently in physical, cognitive, emotional, social, and moral abilities and characteristics.

The individual child may progress and regress in the face of

various challenges and traumas, being “childish” one day and a “young lady” or “young man” the next.
Children manifest much broader developmental and individual variability than do adults. Consequently,
pediatric critical care unit professionals must tailor their approaches and care to the individual state and
abilities of each pediatric patient. The child’s ability to engage in particular aspects of care, including its
ethical aspects, or to move toward particular goals of treatment can vary with the child’s immediate
developmental abilities, themes, challenges, and tasks.

Adults Vs. Pediatric – Differing Ethical Presumptions

Adult-care ethical presumptions:

a. Presumption of patient autonomy

b. Presumption of maturity/ownership of values
c. Presumption of full accountability
d. Ethically: Presumption of obligation to respect
e. Presumption of family insight into the patient’s values
f. Greater potential for conflict between respecting autonomy and providing “benefit”

Pediatric-care ethical presumptions:

a. Presumption of patient incapacity

b. Presumption of patient immaturity/innocence
c. Presumption of developmental accountability
d. Ethically: Presumption of need to protect
e. Presumption of parental authority over their child’s values-development
f. Greater potential for conflict between parental authority and avoiding harm

The Family Is the Patient

 o Care for the critically ill child must be family-centered. Family-centered care is an approach to
healthcare that shapes healthcare policies, programs, facility design, and day-to-day interactions
among patients, families, physicians, and other healthcare professionals. Healthcare professionals
who practice family-centered care recognize the vital role that families play in ensuring the health
and well-being of children and family members of all ages.

o These practitioners acknowledge that emotional, social, and developmental support are integral
components of healthcare. They respect each child’s and family’s innate strengths and view the
healthcare experience as an opportunity to build on these strengths, and the providers support
families in their caregiving and decision-making roles. Family-centered approaches lead to better
health outcomes and wiser allocation of resources as well as greater patient and family satisfaction.

o Family-centered care in pediatrics is based on the understanding that the family is the child’s
primary source of strength and support and that both the child’s and the family’s perspectives and
information are important in clinical decision making. Family-centered practitioners are keenly
aware that healthcare experiences can enhance parents’ confidence in their roles and, over time,
increase the competence of children and young adults to take responsibility for their own healthcare,
particularly in anticipation of transition to adult service systems.

o Given that the family is the child’s primary source of strength and that the family’s perspectives are
important in clinical decision making, the pediatric critical care unit team has a moral obligation to
the patient’s family and a duty to increase family access to the pediatric critical care unit. Increased
access to the pediatric critical care unit has also resulted in more reports of parental presence during
bedside pediatric critical care unit rounds, complex procedures, and cardiopulmonary resuscitation.

o All patient care units should develop written documentation for presenting the option of family
presence during cardiopulmonary resuscitation (CPR) and invasive procedures. Education programs
should be developed for healthcare staff to include: the benefits of the family’s presence for the
patient and the family, criteria for assessing the family, the role of the professional assigned as the
family support person, family support methods, and contraindications for family presence.

o Family meetings—when pediatric critical care unit professionals and family members join together
to engage in a dialogue and devise a plan of action—are a mainstay of pediatric critical care unit
clinical practice. Often the focus of these meetings is developing a consensus regarding the goals
and plan of care, and they can help everyone assess the situation and participate in the development
of that plan. Collaborative communication builds the foundation on which pediatric care of the
highest possible quality can be created. It serves as the key factor in the solution of most ethical
dilemmas.

Consent or Permission from Parents or Guardians

Parents or guardians usually have the authority to give consent or permission for their child’s healthcare
and participation in research. Reasons for this social policy include, first, that parents in general have the
greatest knowledge about, and interest in, the well-being of their own minor children.

o Another well-recognized reason that parents have legal authority to make these and many other
decisions for their minor children is that parents or guardians must address the consequences of the
choices being made. Clinicians should generally try to respect the parents’ preferences because of
the importance parents play in fostering the child’s well-being and shaping the child’s values.

o Parental consent, like other consents obtained in a medical setting, must be adequately informed.
That is, the parent giving consent must be provided with sufficient information to understand and
authorize the treatment that has been recommended. Clinicians need to reveal all information they
know or should know that would be regarded as important to the parents making the decisions.
 Those seeking consent, for example, should provide parents with information about the diagnosis
and prognosis, so that the parents understand the disease process. Reasonable alternative treatment
options should also be explained, along with the nature, duration, side effects, or potential harms or
benefits of the alternative options. Parents also should be told the likely consequences of no
treatment. Clinicians should then test for understanding of the information, for example, by asking
the parents questions about what was discussed or asking the parents to explain the procedure or
treatment in general terms.

o The person who gives consent must have the capacity to make decisions. The terms competent and
incompetent are often reserved for legal contexts. Courts can make a determination about whether
someone is competent. The presumption is that adults are legally competent and minors are not.

o Minors—in most parts of the country this includes those younger than 18   years and are regarded as
incompetent to make decisions about their own healthcare, especially if the decisions are
momentous. The reality is that many adults lack decision-making capacity, but have not been
declared legally incompetent in the courts, and many legally incompetent minors have good
decision-making capacity. Thus, the legal notion of competence and that of decision-making
capacity should be distinguished.

o For the purposes of healthcare, the term decision-making capacity refers to an individual’s ability to
understand information needed to make informed consent, evaluate this information in terms of
stable personal values, and use and manipulate the information in a reasonable manner. For
important decisions, clinicians should assess how well those giving the consent can understand the
information, deliberate, and make and defend choices. It also is important that those giving consent
communicate choices appropriately. These details should help clinicians decide whether parents or
older minors have the capacity to make important healthcare decisions.

o Consent, assent, or permission also must be given freely (i.e., voluntarily), meaning that it must not
be coerced or manipulated. The fact that the parents may be distraught does not make them legally
incompetent or unable to give consent. If parents are not competent or are making an inappropriate
decision, clinicians may have a legal and moral duty to seek a court order so that the courts can
authorize the needed intervention. Informed consent or permission should have the following
elements:

1. All information or material important to the decision has been disclosed.

2. Those giving consent comprehend or understand the information that has been disclosed.

3. Those giving consent voluntarily agree to participate.

4. Those giving consent are competent to make a decision to participate.

5. Those giving consent agree to the procedure, act, intervention, or research.

In some cases, informed consent can be waived, as in medical emergencies, public health emergencies, or
when parents cannot be contacted.

Parents giving consent or permission should be guided by what is in the best interest of their child. Their
decisions can be challenged, for example, if they endanger the child. The best interest of the child standard
is one of four important standards for medical decision making; the other three are self-determination,
advance directive, and presumed consent. Although the best interest of the child standard is of special
importance in pediatrics, each of the four standards has a role in making healthcare decisions for minors.

Assent and Self-determination

Self-determination, as a standard for healthcare decision making, applies to competent adults and to many
older or emancipated minors. This standard of self-determination presupposes that the person is
autonomous or capable of self-determination, has informed understanding, and makes the choices
voluntarily. The standard honors the basic moral principles mentioned previously; it flows from the moral
principle of autonomy or self-determination and honors individual liberty; and it enables people to make
choices about themselves, assess their own best interest, and develop their own capacities and life plans as
they wish, as long as they do not harm others.

Refusal of Immunization
Despite government initiative of more awareness programs, outreach campaigns and involvement of
influencing personalities, still a large number of parents refuse to vaccinate their children and are mostly
driven by myths.

Refusal of care
Parents have authoritative responsibility to make medical decisions on behalf of the child. This also include
right to refuse or discontinue treatments. However, parental decision making should be guided by the best
interest of the child.

Genetic therapy
This causes elimination of inherited diseases or physical conditions by manipulation of genes. However, it
involves making changes to body’s basic set of genes. Thus, has given rise to many ethical dilemmas.

Withhold Therapy vs. Withdrawal of Treatment

A decision to withdraw or withhold treatment may seem like giving up but it can be directed toward best
interest of the child when effectively collaborated between health team & family members.

Informed Consent
It gives the patient and the family an opportunity to be informed participant in her health care decisions. It
should be in writing and preferably in presence of a witness. This gives legal protection to the nurse.

Coping Skills
The nurse is responsible to cope with their overwhelming situation of a serious diagnosed disease.

Restraining a child
Restring a child may sound oppressive, but at times during certain therapeutic procedures absolutely
necessary to ensure child’s safety and well-being.

Accepting Reality
Losing a child can be the most difficult thing a family will ever go through. In some case parents refuse to
accept the reality and want to perform more treatment. However, the nurse must help family realize the
factual aspect of the situation & help the family to cope with the situation.

Confidentiality
All information of the patient must be guarded with confidentiality. The nurse must not share any
information to anyone outside the health team, parents or authorized family members. Violating patient’s
privacy can end up in lawsuit & the nurse might be in verge of losing his job and license.
 Emotional Attachment
Nurse must not become emotionally attached to the patients & take matters in own hands. The nurse has a
legal obligation to respect the wishes of the patient and family. Violating code of ethics can lead to job and
license loss of the nurse.

Patient’s Advocate
If a patient’s condition becomes alarming during any part of the treatment, the nurse must alert the
physician, even in emergency basis if situation be, with a goal to advocate towards patient’s best interest.

Nurse’s Health
The nurse is exposed to regular health hazard such as contraction of infectious disease, injury by sharp
objects, muscular-skeletal problems due to carrying children and babies. However, the nurse must continue
her service toward patients & give all efforts to resolve own health issues.

Ethical dilemma
Nursing is a science of uncertainty and an art of probability. In the ever-existing circumstance of
uncertainty and probability, the nurse often goes through ethical dilemma.
An ethical dilemma is one in which a person has tochoose between two
options, both of which are morally correct but in contradiction. Nurse must choose between two equally
unsatisfactory alternatives. In the dilemma must be resolved by keeping patient’s interest in mind. Some
common dilemmas faced by nurses are:
a) Inappropriate medication order.
b) Unresponsive physician during medical emergencies.
c) Assignment of task before proper training & exposure.
d) Patient’s autonomy violation vs. life-threatening patient’s decision.

 TH E E TH IC AL D E C IS IO N -MAKIN G P R O C E S S
Step 1 Collect relevant information & facts about the clinical situation.

Step 2 State the dilemma.

Step 3 List the possible courses of action for resolution.

Step 4 Analyze the advantages & disadvantages of each action.

Step 5 Make the national decision after family into confidence.

 CLINICAL SIGNIFICANCE OF ETHICAL PRACTICES:

  Ethical values are essential for all healthcare workers. Ethical practice is a foundation for nurses,
who deal with ethical issues daily. Ethical dilemmas arise as nurses care for patients. These
dilemmas may, at times, conflict with the Code of Ethics or with the nurse's ethical values. Nurses
are advocates for patients and must find a balance while delivering patient care. There are four main
principles of ethics: autonomy, beneficence, justice, and non-maleficence.

 Each patient has the right to make their own decisions based on their own beliefs and values. This is
known as autonomy. A patient's need for autonomy may conflict with care guidelines or suggestions
that nurses or other healthcare workers believe is best. A person has a right to refuse medications,
treatment, surgery, or other medical interventions regardless of what benefit may come from it. If a
patient chooses not to receive a treatment that could potentially provide a benefit, the nurse must
respect that choice.

 Healthcare workers have a duty to refrain from maltreatment, minimize harm, and promote good
towards patients. This duty of particular treatment describing beneficence. Healthcare workers
demonstrate this by providing a balance of benefits against risks to the patient. Assisting patients
with tasks that they are unable to perform on their own, keeping side rails up for fall precautions, or
providing medications in a quick and timely manner are all examples of beneficence.

 All patients have a right to be treated fair and equally by others. Justice involves how people are
treated when their interest competes with others. A current hot topic that addresses this is the lack of
healthcare insurance for some. Another example is with patients in rural settings who may not have
access to the same healthcare services that are offered in metropolitan areas.

 Patients have a right to no harm. Non-maleficence requires that nurses avoid causing harm to
patients. This principle is likely the most difficult to uphold. Where life support is stopped or
patients have chosen to stop taking medication that can save their lives, the nurse is put in a morally
challenging position.

 Nurses should know the Code of Ethics within their profession and be aware and recognize their
own integrity and moral character. Nurses should have a basic and clear understanding of key
ethical principles. The nursing profession must remain true to patient care while advocating for
patient rights to self-identify needs and cultural norms. Ethical considerations in nursing, though
challenging, represent a true integration of the art of patient care.

Nurses have a responsibility to themselves, their profession, and

their patients to maintain the highest ethical principles. Many organizations have ethics boards in place to
review ethical concerns. Nurses at all levels of practice should be involved in ethics review in their targeted
specialty area. It is important to advocate for patient care, patient rights, and ethical consideration of
practice. Ethics inclusion should begin in nursing school and continue as long as the nurse is practicing.

 CONCLUSION:

It is unfortunate but true that in a developing country, economic and social realities may outweigh and
override the ethical consideration. The sound ethical facts, logic which must be justified and recorded in a
case file after discussion with the entire health team and by taking parents into confidence. The ethical and
cultural issues & conflicts must be solved professionally by the nurse considering the personal values of the
child and family.

 BIBLIOGRAPHY:

1. Dutta Parul, ‘Pediatric Nursing”, Published by Jaypee Brothers Medical Publishers; 4th Edition
2018, page no: 10-12
2. Singh Meharban, ‘Care of the Newborn’, Published by CBS Publishers & distributors, 8th Edition,
2017, page no: 201-108

3. American Association of Critical Care Nurses: AACN standards for establishing and sustaining
healthy work environments: a journey to excellence. Am J Crit Care 14:187-197, 2005.

4. Belitz J, Baley RA: Clinical ethics for the treatment of children and adolescents: a guide for general
psychiatrists. Psychiatr Clin N Am 32:243–257, 2009.

5. https://clinicalgate.com/ethical-issues-in-pediatric-critical-care/

6. https://www.researchgate.net/publication/285743959_Ethical_issues_in_pediatrics

7. https://www.ncbi.nlm.nih.gov/books/NBK526054/