INTRODUCTION

The original meanings of the terms morals and ethics are similar. The word moral, derived from the
Latin mores, meant customs and habits; the word ethics, derived from the Greek ethos, meant
customs, habitual usage, conduct, and character. In current discussion, the terms are sometimes
used interchangeably, although their definitions are somewhat different.

Morals are personal or codified standards of conduct derived from societal expectations of behavior.
They are the standards of behavior and values to which we are committed as members of society.
Ethics, a more formal term, refers to the systematic study of those standards and values. Ethical
inquiry, a form of philosophical or theological inquiry, allows us to think reasonably about, to
question, to critique, and ultimately to understand the dimensions of moral conduct. The term ethics
is used specifically to mean a method of inquiry that helps us answer questions about what is right or
good, what ought to be done in specific situations, what kind of people we want to be and why

BIO ETHICS

Bioethics, a form of normative applied ethics, is the study of ethical issues and ethical judgments
made within the biomedical sciences, including the delivery of health care.

NURSING ETHICS

nursing ethics is the ethical analysis of judgments made by nurses, and the same moral issues
emerge whether one is the nurse, physician, or patient. Others have contended that nursing ethics is
a separate and unique field of inquiry built on an understanding of the nature and philosophy of
nursing and the nurse-patient relationship. In either case, nursing ethics is best understood as being
built on the specific professional roles and responsibilities of the nurse and on the relationships the
nurse has with the patients), other health care providers, the institutions with which he or she is
affiliated, and society.

THE TOOLS OF ETHICS

Resolution may seem impossible when we are involved in moral conflict. Systematically applying the
tools of ethics, basic moral principles, and nursing's professional guide-lines, however, helps us
identify our ethical obligations and decide which "right" actions can help us meet them.

A systematic decision-making process is another tool that can help us identify and meet ethical
obligations.

Multidisciplinary collaboration and dialogue and consultation with ethics committees or experts,
when indicated, are also critical to achieving satisfactory resolution often problems

Systems of Ethical Thought

Within normative ethics, there are two major ethical systems used to determine what is right or
wrong. The first category, consequentialist theories, includes theories that determine an action to be
right or wrong on the basis of its consequences. Utilitarianism is, today, chief among the
consequentialist theories. For utilitarians, the right action is that which offers the greatest good for
the greatest number. The second category, deontologic or non-consequentialist, includes theories
that judge an action right or wrong on the basis of features other than consequences, usually on the
basis of the conformity of the action to a moral rule.

Both utilitarian and deontologic theories use principles and rules, although for different reasons.
When applying basic moral principles to specific situations, we should remain aware of our own
professional values and obligations that color our ethical reasoning. Awareness of differences in
professional and personal obligations can provide insight into sources of interprofessional or
interpersonal ethical conflict.

Ethical Principles and Care

Four widely accepted bioethical principles apply to ethical problems in health care. These principles
are also pertinent to analyzing moral choices and conflicts faced by practicing nurses. These include
nonmaleficence, beneficence, respect for autonomy, and justice

Two other principles, less frequently discussed in the ethics literature as basic principles but relevant
to nursing practice, are fidelity and veracity.

Fidelity is the duty to be faithful to one's patients, to keep promises, and to fulfill contracts and
commitments. It is the moral covenant between individuals in a relationship.

Veracity is the duty to tell the truth and not to lie or deceive others.

NONMALEFICENCE AND BENEFICENCE

The principle of nonmaleficence says that we have an ethical duty not to inflict harm or evil. It is a
duty foundational to our society. In other words, the duty not to harm others bears more weight
than the duty to benefit others. Citing statements from the Hippocratic oath and the words of
Nightingale, Jameton argues that "it is more important to avoid doing harm than it is to do good

Beneficence involves taking deliberate steps to benefit another person. Beauchamp and Childress
state that this duty compels us to provide benefits by preventing and removing harm and to balance
benefits and harms by performing a risk-benefit analysis, such as weighing the side effects of a drug
against its therapeutic actions

RESPECT FOR AUTONOMY

Respect for autonomy involves respecting the capacity of an individual to be self-determining, that is,
the capacity to deliberate about actions and life choices and to act on those deliberations without
interference from others. Informed consent is an application of the principle of respect for autonomy
in the health care setting. The nurse's duty regarding informed consent is to see that the patient is
adequately informed, has the capacity to understand the options, and can deliberate and make a
health care decision. If a patient is incapable of making an informed decision, a surrogate is asked to
give consent for the patient. A surrogate is someone who is able to make a "substituted judgment"
for the patient; it is usually a spouse, parent, adult child, or someone previously designated by the
patient as durable power of attorney for health care. Most importantly, it is someone who knows and
can represent the wishes and feelings of the patient regarding the treatment options.

It is not uncommon for patients in the ICU to have compromised autonomy and decision-making
capacity due to critical illness and its management. Although important in every health care
interaction, assessment of an individual's ability to understand treatment options and make
decisions in the ICU should be frequent and careful. Respect for the autonomy of the patient may be
manifested through a surrogate decision maker or an advance directive. Respect for people is the
overriding principle under which respect for autonomy falls.

JUSTICE
Justice is a principle of fairness. In the context of health care, the most frequent appeal is to
distributive justice, which requires an equitable distribution of burdens and benefits.

ETHICAL DECISION MAKING WITHIN A NURSING

PROCESS MODEL

Aspects of a moral conflict include interests of the patient, professional and personal values of health
care profession-als, institutional values, personal feelings, moral principles, and legal issues. At first
glance, it might seem impossible to integrate them into anything other than an incoherent mass of
conflicting possible actions.

Ethical decision-making models provide a process for systematically and thoughtfully examining a
conflict, ensuring that participants consider all important aspects of a situation before taking action.
The steps of ethical analysis and evaluation are much like the steps of the nursing process. Both
provide an orderly approach to problems.

There are usually five steps to resolution of an ethical problem in the clinical setting.

GATHER THE RELEVANT FACTS

The first step is to identify information needed to understand the situation fully. What are the
medical facts (ie, di-agnoses, prognoses, treatment alternatives)? Who are the principle agents
involved? Who are the decision makers and the stakeholders? Are the values and goals for treatment
and care of the patient clear? How do the values, interests, and relationships of others involved
affect the problem? Are cul-tural, religious, or other aspects relevant to this situation?

It is important to understand the various contexts of the situation, including the physiological,
psychosocial, and legal dimensions. Are there legal ramifications, institutional policies, or economic
factors to consider?

IDENTIFY THE PROBLEM

The next step is to identify the ethical problems). Is this truly a problem involving conflicting ethical
principles or values, or is it primarily a legal issue or a communication problem? Communication
problems and legal restrictions are often part of an ethical problem; however, some problems can be
resolved simply through better communication or legal counsel without ethical analysis.

ANALYZE THE PROBLEM USING ETHICAL

PRINCIPLES AND RULES

It is essential to identify the person who is to make the final decision. Is the patient competent, fully
informed, and free to choose (consistent with application of the principle of respect for autonomy)?
Is there a family member able to speak to the best interests of a comatose patient (beneficence) or a
designated durable power of attorney for health care who knows the patient's wishes (respect for
autonomy)? Are there vested interests to consider?

Consider ethical principles.

ANALYZE ALTERNATIVES AND ACT

Identify all the possible and reasonable alternatives, and evaluate each of them on their conformity
to principles and rules and their compatibility with care and compassion for the patient. Will each of
the options respect the autonomy of the patient? Is the patient fully informed and freely con-
senting? How is the family involved? Is there a designated surrogate? How will each proposed action
and its outcome benefit or harm those involved? Will the action strengthen or jeopardize patient-
professional bonds and reaffirm society's expectations of health care professionals?

When considering alternatives, nurses must evaluate their position and involvement in the case.
Often the nurse is not the primary decision maker. However, because the nurse is an integral
member of the health care team, it is important that she or he contribute to the dialogue, facilitate
communication, articulate relevant personal views and values, and cooperate in implementation of
the course of action. The nurse's role also includes planning a multidisciplinary conference or
arranging for an ethics consultation.

EVALUATE AND REFLECT

After the action has been taken, the ethical problem, the process of resolution, and the outcome
must be further analyzed. Compare the outcome with what was hoped for or intended. How can a
similar situation be handled with greater sensitivity or wisdom in the future? Evaluation is especially
helpful if it is undertaken in a quiet, nonthreatening atmosphere conducive to reflection

Ethics Committees and Consultant

Services

Ethics committees are multidisciplinary and should include representatives of the professions and
disciplines involved in patient care (ie, nursing, medicine, social work, spiritual care, and others). In
addition, at least one member of the lay community should be a part of the ethics committee. A
lawyer, an ethicist, clergy, and others may be members of the committee or serve as ad hoc
consultants.

Ethics committee members should be involved in self-education as well as education of the

professional staff and community on issues related to clinical ethics.

Because society seems to be more litigious than ever, legal issues involving critical care are of
increasing concern. The number of malpractice suits that name or in-volve nurses is increasing.
Issues such as refusal and termination of treatment have been widely discussed and addressed in the
literature. Even legislatures have acted-so-called living will statutes have been enacted in many
jurisdictions

NURSING NEGLIGENCE IN CRITICAL CARE

The legal responsibility of the registered nurse in critical care settings does not differ from that of the
registered nurse in any work setting. The registered nurse adheres to five principles for the
protection of the patient and practi-tioner. These responsibilities are listed in the accompanying
display.

The most common lawsuits against nurses and their employers are based on the legal concept of
malpractice, which is negligence by a professional. The following discussion emphasizes the major
elements of malpractice and provides some case examples for clarification.

Five Legal Responsibilities of the Registered Nurse

• Performs only those functions for which he or she has been prepared by education and experience

• Performs those functions competently

• Delegates responsibility only to personnel whose competence has been evaluated and found
acceptable

• Takes appropriate measures as indicated by observations of the patient

• Is familiar with policies of the employing agency

Duty and Breach of Duty

A duty is a legal relationship between two or more parties.

Several different kinds of situations can create this type of legal relationship between the nurse and
the patient. Most commonly, the duty element in malpractice is established when the patient enters
the hospital or health care facility.

The admission creates a binding contract on the patient or his insurer to pay for all services
rendered. The health care team is obligated to provide reasonable services in exchange for the fees
charged.

A nurse who cares for a patient is legally responsible for providing reasonable care under the
circumstances present at the time of the incident. The critical care nurse who fails to provide
reasonable care under the circumstances has breached (violated) his or her duty toward the patient.

Causation

Malpractice law also requires that there be a causal relationship between the conduct of the critical
care nurse and the injury to the patient, and the injury that the patient suffers must be reasonably
anticipated.

Injury

To recover monetary damages in a malpractice suit, the plaintiff has to show that some type of injury
or harm occurred as a result of the nurse's actions or inaction. The law allows monetary damages for
several different types of harm.

ISSUES THAT INVOLVE LIFE-SUPPORT MEASURES

Several basic issues regarding refusal and termination of treatment can involve the critical care
nurse. Do not resuscitate (DNR) orders, refusal of treatment for religious rea-sons, advance
directives, and withdrawal of life support all fall into this category.

Do Not Resuscitate Orders

It has been reported that cardiopulmonary resuscitation

(CPR) takes place in 30% of patients who die at a major Boston hospital. 10 However, CPR is not
appropriate for all patients who experience a cardiac arrest because it is highly invasive and may
constitute a "positive violation of an individual's right to die with dignity." Furthermore, CPR may not
be indicated when the illness is terminal and irreversible and when the patient can gain no benefit.

Refusal of Treatment for Religious Reasons

Advance Directives: Living Wills, Health Care Agents, and Powers of Attorney

A living will is a written directive from a competent patient to family and health care team members
concerning the patient's wishes in the event the patient is unable to express these wishes. One
difficulty associated with a living will is its limited applicability. In most states, a living will becomes
effective only if the patient is terminally ill or permanently comatose. Consequently, when the
patient is critically ill or temporarily unable to make health care decisions, the living will is not
operative.