Chapter 9

Ethical and Bioethical Issues in

Nursing and Health Care

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Nursing Ethics
 Definition: system of principles that govern the
actions of the nurse in relation to patients,
families, other health care providers,
policymakers, and society

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 Nursing Ethics (cont'd)
 Code of ethics
 Implicit standards and values for the profession
 American Nurses Association Code of Ethics
 International Council of Nurses Code for Nurses

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 Bioethics
 Description
 Interdisciplinary field within health care that has
evolved with modern medicine to address questions
that arise as science and technology produce new
ways of knowing
 Physicians, nurses, social workers, psychiatrists,
clergy, philosophers, and theologians are joining to
address ethical questions in health care

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 Bioethics (cont'd)
 Dilemmas for health professionals
 Life and death
 Quality of life
 Right to decide
 Informed consent
 Alternative treatment issues
 Stem cell research
 Therapeutic and reproductive cloning
 In vitro fertilization; donor insemination
 Surrogate motherhood
 Organ transplantation
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 Bioethics (cont'd)
 Dilemmas created by technology
 Illnesses that once led to mortality are now
manageable and are classified as chronic illnesses
 Cost is a consequence of prolonging life with
technology
 Manipulation of DNA

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 Ethical Decision Making
 Answering difficult questions
 What is safe care?
 When staffing is inadequate, what care should be
accepted or refused?
 What does it mean to be ill or well?
 What is the proper balance between
science/technology and the good of humans?
 Where do we find balance when science will allow us
to experiment with the basic origins of life?

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 Ethical Decision Making (cont'd)
 Balancing science and morality
 Nurses must examine life and its origins, as well as its
worth, usefulness, and importance
 Nurses must determine their own values and seek to
understand the values of others

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 Ethical Decision Making (cont'd)
 Health care decisions
 Decisions are made with the patient, family, other
nurses, and other health care providers
 Nurses must develop a reasoned thought process
and sound judgment in all situations that take place
within the nurse-patient relationship

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 Values Formation
and Moral Development
 Definitions
 Value: personal belief about worth that acts as a guide
to behavior
 Value system: entire framework on which actions are
based
 Values clarification: a process by which people attempt
to examine the values they hold and how those values
function as a part of the whole
 Moral development: forming a worldview and value
system through an evolving, continuous, dynamic
process that moves along a continuum of development

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 Values Formation and
Moral Development (cont'd)
 Examining value systems
 Nurses must examine their own value systems;
values clarification
• Diane Ustal: first nurse leader to describe the role of values
clarification
 Ethics acculturation
 Nurses must commit to a virtuous value system
 Worldview
• Provides a cohesive model for life
• Encourages personal responsibility for living life
• Prepares one for making ethical choices

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 Values Formation and
Moral Development (cont'd)
 Learning right and wrong
• Infants
 Begin with no concept of right or wrong
 If the need for basic trust is met, infants will develop the
foundation for secure moral thought
• School-age children
 Learn that good behavior is rewarded and bad behavior is
punished
 Begin to make choices that are based on an understanding of
good and bad

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 Values Formation and
Moral Development (cont'd)
• Adolescent
 Questions existing moral values and his or her relevance
to society
 Becomes more aware of contradictions in adults’ value
systems
• Adult
 Strives to make sense of the contradictions and learns to
develop own set of morals and values
 Begins to make choices that are based on an
internalized set of principles

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 Values Formation and
Moral Development (cont'd)
 Understanding moral development theory
• Kohlberg’s theory: most widely accepted; a cognitive
developmental process that is sequential in nature
 Rules imposed by authority
 Conformity to expected social and religious mores
 Autonomous thinker who strives for a moral code beyond the
issues of authority and reverence

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1. Wong (Hockenberry et al, 2007) describes
learning right from wrong as being based on
developmental stages. At what developmental
stage is a human first able to integrate values of
significant others into his or her behavioral
system?
A. Infant
B. Toddler
C. School-age child
D. Adolescent

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 Values Formation and
Moral Development (cont'd)
 Moving toward moral maturity
• Quality of complex health care decisions depends on the
level of moral development of the professionals entrusted
with decision making
• Values essential for the professional nurse
 Altruism: concern for the welfare of others
 Autonomy: right to self-determination
 Human dignity: respect for inherent worth and uniqueness of
individuals and populations
 Social justice: acting in accordance with fair treatment
regardless of economic status, race, ethnicity, age, citizenship,
disability, or sexual orientation

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 Moving Toward Moral Maturity
 Ethics acculturation
 Integrity, personal growth, practical wisdom, and
effective problem solving
 Rights of conscience
 Ethical theory and ethical principles can provide
a basis for moving forward as a morally mature
professional adult

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2. A homeless person comes to the emergency
department after being beaten. The nurse asks
permission to remove the tattered clothing and
carefully folds and places the clothing to prevent
further soiling. The nurse informs the legal system
that this person was assaulted and assists with
securing legal representation. The nurse is at which
moral development stage?
A. Unconventional
B. Preconventional
C. Conventional
D. Postconventional

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 Ethical Theory
 Definition: a system of principles by which a
person can determine what ought and ought not
to be done

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 Ethical Theory (cont'd)
 Utilitarianism
 Rooted in the assumption that an action or practice is
right if it leads to the greatest possible balance of
good consequences, or to the fewest possible bad
consequences
 Strongest approach for bioethical decision making—
Which action will lead to the greatest ratio of benefit to
harm for all persons involved?

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 Ethical Theory (cont'd)
 Deontology
 Rooted in the assumption that humans are rational
and act out of principles that are consistent and
objective, and compel them to do what is right
 A decision is right only if it conforms to an overriding
moral duty and wrong only if it violates that moral duty
 All decisions are made in such a way that the decision
could become universal law

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 Ethical Principles
 Purpose of ethical principles
 Establish common ground among nurse, patient,
family, other health care professionals, and society for
discussion of ethical questions and ethical decision
making
 Permit people to take a consistent position on specific
or related issues
 Provide an analytical framework by which moral
problems can be evaluated

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 Ethical Principles (cont'd)
 Autonomy
 Principle of respect for the person: primary moral
principle
 Unconditional intrinsic value for all persons
 People are free to form their own judgments and
actions as long as they do not infringe on the
autonomous actions of others
 Concepts of freedom and informed consent are
grounded in this principle

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 Ethical Principles (cont'd)
 Beneficence
 To promote goodness, kindness, and charity
 To abstain from injuring others and to help others
further their own well-being by removing harm; risks
of harm must be weighed against possible benefits
 Common bioethical conflict results from an imbalance
between the demands of beneficence and those of
the health care delivery system

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 Ethical Principles (cont'd)
 Nonmaleficence
 Implies a duty not to inflict harm
 To abstain from injuring others
 To help others further their own well-being by
removing harm

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 Ethical Principles (cont'd)
 Veracity
 Principle of truth-telling
 Belief that truth could at times could be harmful held for
many years
 Consumers expect accurate and precise information
revealed in an honest and respectful manner
 To develop trust between providers and patients,
truthful interaction and meaningful communication must
occur
 Challenge is to mesh need for truthful communication
with the need to protect

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 Ethical Decision-Making Model
 Situation assessment procedure
 Identify the ethical issues and problems
• What is the issue?
• What are the hidden issues?
• What are the complexities of the situation?
• Is anything being overlooked?

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Ethical Decision-Making Model
(cont'd)
 Identify and analyze available alternatives for action
• What are the reasonable possibilities for action?
• How do the affected parties want to resolve the problem?
• What ethical principles are required for each alternative?
• What assumptions are required for each alternative and what
are their implications for future action?
• What additional ethical problems are raised by the
alternatives?

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Ethical Decision-Making Model
(cont'd)
 Select one alternative
• Integration of multiple factors
• A reasonable and purposeful decision results from the
blending of ethical theory, principles, and values

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Ethical Decision-Making Model
(cont'd)
 Justify the selection
• Decision maker must be prepared to communicate his or her
thoughts through an explanation or the reasoning process
used
• Justification process
 Specify the reasons for the action
 Clearly present the ethical basis for these reasons
 Understand the shortcomings of the justification
 Anticipate objections to the justification

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 Ethical Decision-Making Model
(cont'd)
 Usefulness and application of the situation
assessment procedure
 Certain ethical issues will be resolved within the context
of the patient-provider relationship
 Other ethical issues that may be more encompassing
are addressed in group settings
• Institutional ethics committees are common within heath care
organizations
• Purposes of the committee are to provide ethics education and
assistance with ethical policy development, and to serve as a
consultative body in helping to resolve ethical dilemmas

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Ethical Decision-Making Model
(cont'd)
 Applicable to the daily practice level of ethical
decision making
 Applicable to the policymaking level, where
professionals come together to consider right and
wrong choices that affect society as a whole

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 Bioethical Dilemmas: Life, Death,
and Dilemmas in Between
 Definition
 Dilemmas that pose a choice between perplexing
alternatives in the delivery of health care because of
the lack of a clear sense of right or wrong
 Nurses should consider the dilemmas that might arise
in a given practice setting

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Bioethical Dilemmas: Life, Death,
and Dilemmas in Between (cont'd)
 Life
 Bioethical abortion issue
• When does life begin?
• Nurses serving in women’s and children’s health settings
must be prepared to face this morally laden issue
 Reproduction issue: influenced by genetic screening,
genetic engineering, and cloning

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Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 35
Bioethical Dilemmas: Life, Death,
and Dilemmas in Between (cont'd)
 Death
 Quality of life and definition of death issues: With
advances in health care, what is usual and what is
heroic care has become unclear
 Euthanasia and assisted suicide present new ethical
questions
 Nurses in every setting must be prepared to consider
end-of-life questions

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Bioethical Dilemmas: Life, Death,
and Dilemmas in Between (cont'd)
 Dilemmas in between
 Right to health care
• Health care system more selective in the amount and type of
treatment offered as a result of managed care
• Is each person entitled to the same health care package?
• Does ability to pay affect specific level of entitlement?
• How ethical is gatekeeping in the new managed care
system?
• Access to health care and respect for human dignity are at
the core of nursing practice

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Bioethical Dilemmas: Life, Death,
and Dilemmas in Between (cont'd)
 Allocation of scarce resources
• Should the recipient of scarce resources be selected on the
basis of quality of life? Ability to pay? Best prognosis? First-
come, first-served?
• Nurses should be prepared to consider questions regarding
allocation of scarce resources

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 Ethical Challenges
 The challenge of veracity
 Issues of alternative treatments and acknowledgment of
uncertainty test truth-telling
 Which treatment among two or more is best for the
patient?
 Which of the new drugs should be used?
 Should every patient be subjected to every possible
form of diagnostic treatment?
 Should patient be made aware of questions and various
options surrounding care?
 Is disclosure of uncertainty beneficial or detrimental?

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 Ethical Challenges (cont'd)
 The challenge of paternalism
 Provider tries to act on behalf of the patient and
believes that his or her actions are justified because
of a commitment to act in the best interest of the
patient
 Interferes with a patient’s right to self-determination

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 Ethical Challenges (cont'd)
 The challenge of autonomy
 Makes way for the crucial legal step of informed consent
 When are patients competent to make informed consent
decisions? Can family members or surrogates make decisions
by proxy?
 Questions about informed consent are raised for minors,
confused older adults, mentally compromised, imprisoned,
inebriated, unconscious, and those in emergency situations
 Nurses also must take responsibility for understanding and
educating people about advance directives

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 Ethical Challenges (cont'd)
 The challenge of accountability
 Nurses have an obligation to uphold the highest
standards of practice, to assume full and professional
responsibility for every action, and to commit to
maintaining quality in the skills and knowledge base
of the profession
 Obligation to denounce a harmful action or potentially
threatening situation may fall to a fellow member of
the profession; to remain silent is to consent to the
action of the threatening situation

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