( Introduction to Nursing Ethics )

Definitions
Ethics: (Gk word- ethos=custom or character)
The expected standards of behavior.
OR The principles of conduct governing people.
OR Ethics is the system of moral rules and principles that becomes
the standard for professional conduct.
Bioethics: Ethics applied to life. (eg. Abortion, euthanasia)
Nursing Ethics: Refers to ethical issues involved in nursing practice
Value: Beliefs or attitudes about the worth of a person, object,
idea or action.
Conflict: Mental struggle resulting from incompatible or opposing
needs, wishes etc.
Dilemma: A difficult situation that seems to have no satisfactory
solution.
• Ethical dilemma: is a complex situation that often involves an
apparent mental conflict between moral claims, in which to obey
one would result in transgressing another. This is also called an
ethical paradox.
• OR:- Values in conflict within a professional.
• OR:- Situations necessitating a choice between two equal
(usually undesirable) alternatives.
• OR:- Situations involving conflicting moral claims and give rise
to questions.
• Moral: Is a personal conviction that something is absolutely
right or wrong and good or bad in all the situations.
• Belief: Interpretation or opinion that we accept as true.
• It is based on faith not on fact.
• Belief is judged as correct or incorrect.
• Attitude: Feeling or emotion including positive or negative
judgment toward a person, object, or idea.
• It is often judged as good or bad, positive or negative.
Moral imperative is a principle originating inside a person's mind that compels that person
to act.
 Importance of Ethics in Nursing
• Ethics provides a frame of reference for decision making and
action to be taken in a complex situation.
• It provides us with the rules and principles to ethical decision
making.
• Provides a base for regulating the relationship between nurse,
patient, coworkers, society and profession.
• e.g. Dilemma, Abortion, Euthanasia (mercy killing)
• It gives us standards of practice and profession.
• Ethics in nursing promotes the sense of fundamental
responsibilities of nursing care as to promote health, to restore
health, to prevent illness and to alleviate suffering.
• It fuels the development of caring attitude, sense of
responsibility and accountability.
• It promotes an environment in which the values, customs and
religious belies are respected.
• Ethics tells to hold in confidence personal information and to use
judgment in sharing this information where necessary.
Criteria of Nursing Characteristics of a
Profession Professional Nurse
• Body of • Caring/Honest/Faithful/Patient
knowledge • Good listener
• Accountable/Competent
• Confident
• Advancement of • Commitment
knowledge • Reflective
• Non judgmental
• Responsibility • Safe care provider
and • Maintain ethical standards in
accountability practice
• Encourage peer to follow the same
• Follows policies and procedures
• Client benefit
defined by the institution
• Maintains ethical conduct
• Code of conduct • Responsible
 ( Value Set )
• Value: Beliefs or attitudes about the worth of a person,
object, idea or action.
• Belief: Beliefs are the assumptions we make about
ourselves, about others in the world and about how we
expect things to be.
• Attitude: Feelings toward a person, object or idea
(e.g, acceptance, rejection, etc.)
• Value set: A group of values held by a person.
• Values clarification: is a process by which people
identify, examine, and develop their own individual
values.
 Classification of Values
• There are two basic types of values
• 1. Intrinsic Value: Refers to the maintenance of life
i.e food and water that are necessary for life.
• 2. Extrinsic Value: Originates outside the individual
and not necessary for life i.e health, humanism etc.
Values can be positive or negative
• Positive Value: A positive value is a view of how
something should be. e.g: To respect someone.
• Negative Value: A negative value is a view of how
something should not be. e.g: To disgrace someone
or being unkind to someone.
 Types of Values

Values are classified as:

• Personal Values---- self-respect, peace
• Professional Values ----
• Political ----power
• Economic ----usefulness
• Aesthetic ---- beauty
• Social ----human interactions
 Personal Values
These are individualized values that are mostly derived from
society.
• For Example:
• Family unity, Self-worth, worth of others, religion,
Independence, Honesty, Love, sense of humor, Safety,
Peace, Money, work, travel, Plants, animals, etc.
Professional Values
Nursing professional values are acquired via socialization into nursing,
from code of nursing, experiences, teachers and peers.
For example
• Strong Commitment to service
• Belief in the dignity and worth of others
• Commitment to Education
• Professional Autonomy
• Professional characteristics
 Moral Values
• Moral values are the personal standards of good and evil,
which govern an individual’s behavior and choices.
• Moral values are usually innate.
• A situation is responded with words like ought, should,
right, wrong, good and bad.
• Moral issues are concerned with social values and norms.
• Examples:
• Respect, Goodness, truth, etc.
Societal Values
• Values that are concerned with society and are directed to
social considerations.
• Examples:
• Human life, Individual rights, individual autonomy, equal
opportunity,
• health, education, friendship, etc
 Identifying Personal Values
• Nurses need to know what values they hold about, for
example, life, health, illness, and death.
• They should also explore their own values regarding
• Individual’s right to make decision for self
• Abortion
• Euthanasia (Active and Passive)
• Blood transfusion/ Tissue transplantation
Identifying Client’s Values
• Nurses need to explore the client’s values and not to
assume that their own are superior. This attitude will allow
the nurse to build an effective rapport with patients who
have differing values.
• The clients’ values influence and relate to a particular health
problem which may need more attention.
 Values Clarification
• Definition: is a process by which people identify, examine, and
develop their own individual values.
• A principle of values clarification is that no one set of values is right
for every one.
• Identification and clarification of Values is based on choosing a
value freely and consciously.
Theory of Values Clarification
In 1966, Raths, Harmin and Simon proposed a theory of values
clarification as:
• Choosing (cognitive):
Values and beliefs are chosen freely without outside pressure after
reflecting and considering its consequences.
• Prizing (affective):
• Chosen beliefs need to be happy and satisfied with.
• Acting (behavioral):
• Chosen beliefs and values are incorporated into one’s behavior.
• It needs to be repeated consistently in life.
 Values Transmission
• Values are learned through observation and experience. We
accumulate our values from childhood via teaching and
observation of our parents, teachers, religious leaders, and
other influential and powerful people.
• Values are highly influenced by a person’s family,
sociocultural environment, and peer groups. For example, if
a parent consistently demonstrates honesty in dealing, the
child will probably begin to value honesty.
• Similarly, some cultures prefer folk treatment over new
medicine which is learned from culture.
What begets what!
• From right understanding proceeds right thought
• from right thought proceeds right speech
• from right speech proceeds right action
 Lily Flower in pond
• The roots of the lily – our beliefs, deeply held
• The low stalk – our values, based on these beliefs
• The high stalk – our attitudes towards the world
• The leaf on the surface – our behavior, that others
see
Class Activity
Identify value and belief in the given examples as:
• “I believe if I work hard I will get a good grade”.
• If I do good to others I will have good.
• If I respect others I will receive respect in return.
 ( Values Conflict )
Definition: Internal or interpersonal conflict that occurs in
circumstances in which personal values are at odds with those of
patients, colleagues or the institution.
• Interpersonal values conflict and issues arise in nursing when
one’s values either personal, cultural, religious or any to be
opposed or imposed.
Values Confliction in Nursing
Values confliction and issues arise in health care system. Nurses
experience values confliction with clients, clients’ families,
physicians, employing institutions and licensing bodies. Similarly,
the clients’ needs may conflict with institutional policies, physician
preferences, or even laws of the state. According to code of ethics,
the nurse’s first priority is the patients’ needs. However, it is not
always easy to determine which action best serves the clients’
needs. For example, a nurse may believe the patient’s interests
require telling the patient a truth that physician has been
withholding. But telling the truth may affect the client-physician
relationship adversely and may cause harm to the client rather than
the intended good.
 Values Clarification
• Definition: Values clarification is a process by which people identify and
express their values.
• A principle of values clarification is that no one value set is right for
everyone.
• By following seven steps a nurse may help others to clarify their own values.
How to clarify values
1. List Alternatives: A person needs to be aware of alternative actions and
their consequences.
2. Examine possible consequences of choice: Compare advantages &
disadvantages
3. Choose Freely: The person should be free from external pressure.
4. Feel good about the choice: It needs to be determined how the person
feels about the decision------satisfied with or not.
5. Affirm the choice: The person should be expressive to others about the
decision.
6. Act on the choice: The person should be prepared to act on the decision.
7. Act with a pattern: To know whether the person behaves consistently.
When implementing these steps, the nurse should be neutral---means not to
offer an opinion or judgment except when a person asks for opinion. Be
careful in giving opinion.
 Advantages
• Values clarification promotes personal growth by
fostering awareness, empathy and insight.
• It provides opportunity to explore values and beliefs.
• It allows you to discuss values in a safe environment
• It deals with feelings and emotions proactively.
• It allows individual and group discussion.
• Defined values give direction to your life.
• Values facilitate decision making based on what is
important to you.
• By knowing others' values, it allows you to work more
effectively with them. Their values may not coincide
with yours, but it is what’s important to them.
• The clearer you are about you values and beliefs, the
happier and more effective you will be.
 Developing Professional Values
• Nurses’ professional values are developed during
socialization into nursing, that is, codes of ethics,
nursing experiences, teachers and peers. There are
four basic nursing professional values (Watson, 1981).
1. Strong commitment to services
2. Belief in the dignity and worth of others
3. Commitment to education
4. Professional autonomy
• American Association of Colleges of Nursing (AACN,
1986) identified seven essential values of nursing
profession as:
• Altruism, equality, esthetics, freedom, human dignity,
justice, and truth.
Implication of Nursing Care Ethics in Diverse Society
• Nurses care patients with different ethnic and
sociocultural background. The effective
relationship and holistic care include the
consideration of all the aspects of diversity in
culture, society, religion etc. A nurse needs to:
• Respect for cultural differences.
• Be knowledgeable of the cultural practices of
clients.
• Be aware of own values and biases.
• Know that all clients are individuals and may not
share the same views and values as others even
within the same ethnic group.
 ( Ethical Principles )
• Ethical principles are a set of ethical rules that provide the
framework / tools which may facilitate individuals and society to
resolve conflict in a fair and moral manner.
The ethical principles are as follows:
• Autonomy: Refers to the right to make one’s own decisions and
choices.
• Veracity: Refers to telling the truth.
• Confidentiality: Respect for a person’s privacy.
• Beneficence: The principle and obligation of doing good and
avoiding harm.
• Nonmaleficence: The duty to do no harm.
• Justice: The principle that deals with fairness, equity and
equality .
• Fidelity: Means to be faithful to agreements and promises.
• Accountability: Answerable to oneself and others for one’s own
actions
 Ethical Dilemma
• Many of our ethical issues arise when dealing with the beginning
of human life or the end of human life and the use of technology.
There are so many others.
• Nurses face different ethical dilemmas in a health care system
For Example:
• How should a nurse allocate her/his time and effort when caring
for 8 acutely ill patients? Time and effort are resources.
• What should a health professional do when he/she sees a
colleague engaging in an unethical act?
• Because of the family’s wish, the terminal ill status has not been
told the patient but the nurse is sure he/she knows he/she is
dying. What should the nurse do ethically when this patient
directly asks her/him about his/her condition?
• Is lying to a patient ever ethical? What constitutes a lie? Is a
placebo a lie?
• Should the nurse follow a doctor’s order if she/he thinks there is
a potential problem with the order?
• Two ethical principles are ‘Do No Harm and Do Good’. What
do we mean by Harm and Good?
• Health professionals have two basic ethical obligations:
(1) to extend life & (2) to lessen pain and suffering.
• Can they do both in this situation when morphine may
shorten patient’s life?
• Should more money be spent on prevention than on acute
care and especially on terminal care? How ethically justify
spending money on futile medical care?
Scenario
A patient, 30 years old is hospitalized with AIDS. Next day his
parents come to see him. The patient requests his nurse if his
parents asks his diagnosis please tell another one like
leukemia etc. instead of AIDS.
• What the nurse should do here?
• Veracity or confidentiality?
 Strategies to Resolve Ethical dilemma
1. Identify ethical issues and problems
2. Look at the dilemma from different perspectives:
• What are the consequences of each choice?
• Who is affected and in what ways?
• Examine the choices against well accepted moral
laws?
• Look at the choices using the ‘Golden Rule’ – How
would I like to be treated under similar
circumstances?
3. Identify and analyze available alternatives
4. Select one alternative
5. Justify the selection
 Ethical Decision Making
• Responsible ethical reasoning is rational and systematic. It
should be based on ethical principles and codes of ethics
rather than on emotions intuition, fixed policies, or
precedent.
• A good decision is one that is in the client’s best interests
and at the same time preserves the integrity of all involved.
Steps of Ethical Decision Making
• Identify the moral aspects.
• Gather the relevant facts that relate to the issue.
• Determine ownership of the decision. i.e for whom is the
decision being made? Who should decide and why?
• Clarify and apply personal values.
• Identify ethical theories and principles.
• Identify applicable laws or institutional policies.
• Use competent interdisciplinary resources.
• Develop alternative actions & project their outcomes on the
client & family.
• For each alternative action, identify the risk and seriousness
of the consequences for the nurse.
• Apply nursing codes of ethics to help guide action.
• Participate actively in resolving the issue.
• Implement the action, and Evaluate the action taken.
Scenario
• Mrs. Reena, a 40 years old woman, is brought to hospital
with multiple fractures and lacerations caused by RTA. Her
husband who was killed in the accident was brought the
same hospital but dead. Mrs. Reena, who had been driving,
freequently questions Ms. Almas, her primary nurse, about
her husband. The surgeon, Dr. Momin, has told the nurse
not to tell Mrs. Reena about the death of her husband;
however, he does not give the nurse any reason for these
instructions. Ms. Almas expresses her concern to the charge
nurse, who says the surgeon’s order must be followed. Ms.
Almas is not comfortable with this and wonders what she
should do.