WEEK 5 - Ethical Decision

Hand Hygiene
Health Law and Ethics
Ethical Decision Making

Semester 1
04/24/24 Physiological & Psychological©Changes indeveloped

2006, original content Pregnancy 1
Original material supplied by Health Protection Scotland. Responsibility for the editing and use of these materials lies with the individual and not Health Protection Scotland or Healthcare A2Z.
by Healthcare A2Z, www.healthcareA2Z.org fchs.ac.ae
Hand Hygiene
Learning Outcomes
By the end of the lecture, the students are expected to:
1. Distinguish between practical problems and ethical dilemmas.
2. Differentiate the moral uncertainty, moral distress and identify the

other moral problems.
3. Examine the process of thoughtful decision making.
4. Describe the role of emotions in ethical decisions.
5. Apply ethical decision making to clinical case scenarios.

© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org fchs.ac.ae
Introduction
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Each of us makes decisions every day. These decisions are likely routine and not
that difficult to make.
Class Participation Exercise:
i.Give some of examples of the type of daily decisions you make at home
ii.Now give some of examples of the type of decisions you make in nursing.
 These decisions may be routine patient care management matters, but they can
also involve complex matters, such as when to discontinue feeding a dying patient.
These decisions do not come easily and, as nurses, we may grapple with them.
Introduction cont.
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 Studies have shown that “30 - 50% of nurses leave bedside patient care
because of moral distress” (Burkhardt & Nathaniel 2014, p. 136);- the
stress caused by ethical dilemmas.
 If nurses are informed about ethics and fully involved in decision making
around moral dilemmas in practice, perhaps more nurses would stay at
the bedside.
Ethical/Moral Problems
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How Do We Know When a Problem is an Ethical One?
Definition of “problem”
 A problem is “a discrepancy between the current situation and a desired
state” (Burkhardt & Nathaniel 2014, p. 117)
 Problems, of a practical or common nature, are usually:
 Unplanned ; Unexpected
 Personal in nature (self-interest is the primary concern)
 Not morally laden
 These problems can be solved once the relevant information and resources are gathered.
Ethical/Moral Problems Hand Hygiene
Ethical or moral problems are different from common problems in that they
usually:
 “Have no easy solution
 Are associated with value laden terms such as, good, bad, harm, benefit, should,
ought to, right, and wrong
 Involve uncertainty and conflict
 “Are not reversible once a decision is made” (Burkhardt & Nathaniel 2014, p.118)
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A Moral problem can be defined as a moral matter or issue, that is
difficult to solve or overcome, and requires a “ moral solution”, with
varying degrees of difficulties and complexities, and can lead to moral
distress. (Johnstone, 2010)
Ethical/Moral Problems Hand Hygiene
examples
 Problem: A patient in severe and intolerable pain due to not receiving pain
medication.
 Practical/Clinical/Technical: the cause of it is neglecting the patient’s pain, so
by the thorough assessment of the patient and administering the analgesia, we
will solve the patient’s problem.
 Ethical/ Moral: If the pain was due to the patient’s refusal of pain relief based on
religious grounds, giving the analgesia is not allowed by the moral demand to
respect the patient’s autonomous wishes, and the nurses’ moral interest in not
suffering.
04/24/24 SUBTILE 2 : MAIN TITLE 8
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The most 10 forms of moral problems
1.Moral unpreparedness
2.Moral blindness
3.Moral indifference
4.Amoralism
5.Immoralism
6.Moral complacency
7.Moral fanaticism
8.Moral disagreements and conflicts
9.Moral dilemmas
10.Moral stress, or distress
1. Moral unpreparedness Hand Hygiene
Moral unpreparedness is being unprepared to deal with a moral issue
The reasons can be due to moral incompetency or impairment, lack knowledge or
expertise to realize what is the situation, and not able to deal with its complexities.
This situation, not only can make the nurse inadequate, but also dangerous, as
decisions can be made where there is a lack of moral competence
Example: Moral unpreparedness, resembles clinical unpreparedness.
“A nurse walks into her new unit appointment, turns out to be ICU, and she receives a patients
on a ventilator, that she has never learnt anything about, or even saw one before!”
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2. Moral blindness :
 A moral blind person, is someone who simply
does not see the moral problem as a problem! Instead, he/she

sees it as a technical /clinical issue.
 Nurses are so conditioned by the clinical context, to the
point that they miss to see a moral problem.
 Example : DNR/ NFR orders*- “RN never thought of it as moral
issue” ,before it was a clinical issue decided by doctors, and not
moral issue decided by ethicists.
3. Moral indifference Hand Hygiene
Moral indifference
Unconcerned or care-free attitude towards moral issues or demands
 “Why bother to be moral?”
 Usually such persons do not express any wish or opinion towards doing, or
not doing an action.
Example 1: Applying horn in street!
Example 2: A nurse who is not interested in alleviating patient`s pain despite his
complaint, or result of her assessment ! ( or Not interested in any form of violation
of the patients’ rights).
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4. Immoralism
Immoralism is deliberate violation of accepted or agreed ethical standard during

conduct that is viewed as the right thing to be done, or morally correct.
Could be either :
a)Moral turpitude: (social private duty) anything done on purpose against what is right
and contrary to ethical principles.
b)Moral delinquency: any act that involves negligence of a moral duty (carelessness or
deliberate violation of agreed standards of ethical professional conduct).
Class participation: discuss examples on each

5. Amoralism
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Amoralism is a state of absence of moral concern, and even a rejection

of morality altogether.
An amoral nurse may reject to have a duty toward patients, or even
reject the idea that patients have rights!
 (rejecting to uphold the patient’s rights, as it doesn’t make sense to talk
about the patient’s rights for them).
A very similar analogue: is the refusal of an atheist to religious terms
(debate the existence of god).
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6. Moral complacency:
Moral complacency is a decline to accept that your own moral judgment is

possibly wrong
Those people just cannot accept the fact that they can be mistaken, and so cannot
also accept that others can be right as well
Example: A nurse with 30 years of experience in elderly home, who insists that it is right
and proper that all elderly patients should be uniformly designated to DNR upon admission
to a residential nursing care home , even without obtaining their permission .
7. Moral fanaticism: Hand Hygiene
A morally fanatic person is, someone who is absolutely convinced with certain
ideals (believes), following those ideals without even reflecting, or critically
thinking about those ideals.
In health care setting; a health care professional, might impose his/ her own
moral believes on patients despite their wishes, or choice of importance.
Example: a doctor who insists that being honest to the patients about their condition is
the most important thing, disregarding their autonomy.
8. Moral disagreements and conflicts Hand Hygiene
These come in two types: 1. Internal moral disagreement and
2. Radical moral disagreement
a) Internal moral disagreement

 Agreeing on that two moral /ethical principles are important, but disagree on
what to do when these standards come into conflict, and which comes first, or
more important.
E.g. : Two nurses agree and accept the standard of truth telling,
(Nurse A: Favor telling the truth to patient with cancer, Nurse B: Favor not to tell the
truth to patient with cancer to avoid suffering).
a) Internal moral disagreement cont.

To agree on moral/ethical standards, but to disagree on what counts as
an accepted exception or limitation for this standard.
E.g.: Both RNs agree to prevent the patient’s rights from being violated,
(Nurse A: acts in situations of violation of patient’s rights even if this threatens
her job security, Nurse: B agree to prevent violation patient’s rights from being
violated, but disagree that nurses should do so even if they lost their job). ----
No Resolution --- ( Moral Deadlock )
b) Radical moral disagreement - could be partial, or complete
Partial radical moral disagreement :
Agree on some criteria of relevance but not all.
E.g. : Nurse A: Disagrees on killing a terminally ill patient with a lethal injection but,
agrees on letting the patient die naturally.
Nurse B: Disagrees on killing a terminally ill patient with a lethal injection, but disagree on
letting the patient die naturally.

b) Radical moral disagreement - could be partial, or complete
Complete radical moral disagreement
Don’t agree on any criteria of relevance, and Don’t share any basic moral principles.
E.g. : Nurse A: Rejects retrieving organs from patients who are not fully dead for an organ transplantation
as she considers it as a murder, because its violating the sanctity of life.
Nurse B: Doesn’t consider it as a murder as the sanctity of life has no substance with the quality of life,
(no solution).
9. Moral dilemmas
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Moral dilemmas are the most discussed type of moral problems in ethics and
bioethics.
It is a situation, where you have to make a choice between two things, that
both are equally undesirable, or both desirable.
 This can be due to: logical incompatibility between 2 different moral principles
(ex. P.109), or due to competing moral duties, or when you have competing or
conflict of interests.
Sometimes the decision is related to people or certain attachments .
9. Moral dilemmas cont.
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E.g. A RN who accepts sanctity of life view and another moral principle as non-
maleficence which demands that persons should be spared intolerable suffering
Accepting sanctity of life -- reject administration of large and potentially lethal doses of
narcotics that might be required to relieve the patient’s pain
Following the principle of non-maleficence-- the RN is required to administer these
lethal narcotics.
 ----- in this case the RN is confronted with a dilemma that to uphold the sanctity of life
principle could violate the principle of non-maleficence
Informing patient with cancer about his diagnosis against family wishes.
10. Moral distress, stress, & perplexity Hand Hygiene
Johnstone (2019), defined Moral distress, stress, & perplexity this

concept as:
“ psychological disequilibrium , and negative feeling state, experienced

when a person makes a moral decision, but does not follow through, by
performing the moral behavior indicated by that decision”.
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10. Moral distress, stress, & perplexity cont.
 Moral distress occurs when one knows the ethically correct action to
take but feels powerless to take that action
 This can happen due to institutional constraints, legal barriers, limited
resources, …etc.
 Perplexity can also lead to distress, as it is a state of moral confusion.
Example: Aggressive patient who requires sedation, but the patient’s

power of attorney, opposes any form of sedation.
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10. Moral distress, stress, & perplexity cont.
 Moral distress has been shown to have a major negative impact on

nursing care.
 The consequences of moral distress for nurses include:
 They avoid patient contact.
 They may not give as good patient care.
 Their capacity for caring is strained.
 They leave the profession.

Factors that Confound Ethical Hand Hygiene
Problems
Facing ethical problems leads to difficulty decision making:
Factors that Confound Ethical Problems include:
1. Uncertainty : The lack of predictability of the outcome of a certain action.
2. Context : The world in which the patient lives is critical in defining that person, and influences the
selection of one choice over another.
3. Stakeholders : The number of people that might be involved with the decision and who have
strong or competing differences of opinion in what action to take (patients, family members, close
friends , others) .
Factors that Confound Hand Hygiene
Ethical Problems
Factors that Confound Ethical Problems include:
4. Power Imbalance : The difference in influence of the stakeholders over decisions due to real or perceived
power, and social or institutional power (doctors, nurses, patients)
5. Extraneous Variables : Factors outside the patient care setting that might influence decision making, such
as laws, previous legal cases. e.g.: believing in euthanasia which is prohibited in your country.
Processing an Ethical Dilemma Hand Hygiene
Resolving an ethical problem requires careful deliberation (diligence, vigilance

& wisdom) by patients, caregivers, and healthcare professionals.
This is best achieved when, actions stay focused on what is for the best for
the patient
The decision-making works best when participants:
 Begin with good will toward each other.
 Are collaborative with each other.
 Adhere to respect and confidentiality.
 Are patient focused.
Making Ethical Decisions We Can Justify Hand Hygiene
Giving good reasons for ethical decisions is called moral justification.

Each of the theories and principles discussed earlier can be used as a
starting point in examining a position on an ethical issue.
Different points of view among patients, family, and health professionals can
cause disharmony or moral tension in reaching a solution to a problem.
Coming to agreement about what is in the best interest of the patient
requires nurses to develop consensus building and good communication
skills.
Steps To Ethical Decision Making
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1. Assess the situation:

 Diligent appraisal of facts.
 Operating values in the situation of issue.
Example: assess persons and parties involved, causes, etc…
2. Identify the moral problem you are dealing with:
Example: is it related to religion, culture, race, etc…..
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4. Implement the plan of moral care:
5. Evaluate moral outcomes : if the desired moral outcome has not

been achieved, you may need to re-do the whole process.
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Important questions to ask during steps of ethical decision making might include:
 What is the issue here?
 Are there any hidden issues?
 Where are the conflicts?
 What are the ethical theories/principles that apply?
 What are reasonable alternatives to resolve the problem?
 How do the alternatives rest with my personal/professional values?
 Are you treating others as you would want to be treated?
 How do the key parties want to resolve the problem?
 Would you be comfortable if your decision making were publicized?
Emotions in Decision Making:
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 The ethical decision making approach is largely based on reasoning.
 However, moral dilemmas are emotionally charged situations.
 Callahan (2000) says, it is important that emotions play a role in

informing our ethical decision making.
 Emotions provide information on how we feel about what is right or
wrong in a situation.
Example: inserting IV Cannula for a sick child.

Emotions in Decision Making: Hand Hygiene
 Callahan warns of the seriousness in devaluing feelings in moral dilemmas:

 “numbness, apathy, isolated disassociations between thinking and
feeling are moral warning signs” we must guard against (as cited in
Burkhadt & Nathaniel 2008, p. 127).
 The goal is to have “head and heart in harmony as an ethical decision is

made.” (Burkhadt & Nathaniel 2008, p. 127).
 Sound decision-making requires a collaboration between reason and
emotion
Summary Hand Hygiene
 An ethical dilemma occurs when there appears to be no satisfactory easy
solution to problem and there are conflicts between ethical principles, values,
duties, and rights.
 Ethical problems may cause strong emotional feelings or “moral distress”.
 Moral distress may have significant negatives consequences for patient care.
 Ethical decision making is a reflective process using both reasoning and
emotions.
Summary Hand Hygiene
 Ethical decision making involves defining the problem, identifying a desired goal, gathering
information, comparing options, choosing the best course of action and evaluating the
outcomes of the choice.
 Identification of one’s own value system as well as the value system of the key
stakeholders involved in the ethical situation are critical to how an ethical dilemma is resolved.
 Life experience plays a very major role in dealing with moral issues and moral distress.
 Nurses who practice applying the concepts of ethics and the steps of a decision making
model in the realities of day-to-day practice will develop the competence and confidence
with ethical decision making.

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References:
Burkhardt, M. & Nathaniel, A. (2014). Ethics and issues in contemporary nursing. 4th
Edition. Canada: Delmar Cengage Learning.
Johnstone, M. (2019). Bioethics: a nursing perspective. 7th Edition. Australia: Elsevier
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Lets Review
An ethical dilemma is defined as

a.a real or perceived conflict of values and beliefs.
b.only found in situations regarding withdrawing of life-support.
c.the nurse and the physician do not communicate well with
the patient.
d.None of the above

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Lets Review
In most ethical dilemmas, the solution to the dilemma requires negotiation among
members of the health care team. The nurse’s point of view is valuable because:
a.A The nurse’s code of ethics recommends that a nurse be present at any ethical
discussion about client care.
b.B The principle of autonomy guides all participants to respect their own self-worth.
c.C Nurses have a legal license that encourages their presence during ethical
discussions.
d.Nurses develop a relationship to the client that is unique among all professional health
care providers.


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Hand Hygiene

Health Law and Ethics

Ethical Decision Making

04/24/24 Physiological & Psychological©Changes indeveloped

By the end of the lecture, the students are expected to:

1. Distinguish between practical problems and ethical dilemmas.

2. Differentiate the moral uncertainty, moral distress and identify the

3. Examine the process of thoughtful decision making.

4. Describe the role of emotions in ethical decisions.

5. Apply ethical decision making to clinical case scenarios.

Class Participation Exercise:

How Do We Know When a Problem is an Ethical One?

 Not morally laden

How Do We Know When a Problem is an Ethical One?

How Do We Know When a Problem is an Ethical One?

The most 10 forms of moral problems

Moral unpreparedness is being unprepared to deal with a moral issue

The reasons can be due to moral incompetency or impairment, lack knowledge or

decisions can be made where there is a lack of moral competence

Example: Moral unpreparedness, resembles clinical unpreparedness.

 A moral blind person, is someone who simply

does not see the moral problem as a problem! Instead, he/she

Immoralism is deliberate violation of accepted or agreed ethical standard during

and contrary to ethical principles.

deliberate violation of agreed standards of ethical professional conduct).

Class participation: discuss examples on each

Amoralism is a state of absence of moral concern, and even a rejection

Moral complacency is a decline to accept that your own moral judgment is

also accept that others can be right as well

to a residential nursing care home , even without obtaining their permission .

ideals (believes), following those ideals without even reflecting, or critically

thinking about those ideals.

moral believes on patients despite their wishes, or choice of importance.

These come in two types: 1. Internal moral disagreement and

2. Radical moral disagreement

a) Internal moral disagreement

a) Internal moral disagreement cont.

b) Radical moral disagreement - could be partial, or complete

Partial radical moral disagreement :

Agree on some criteria of relevance but not all.

agrees on letting the patient die naturally.

letting the patient die naturally.

b) Radical moral disagreement - could be partial, or complete

Complete radical moral disagreement

as she considers it as a murder, because its violating the sanctity of life.

Johnstone (2019), defined Moral distress, stress, & perplexity this

“ psychological disequilibrium , and negative feeling state, experienced

Example: Aggressive patient who requires sedation, but the patient’s

 Moral distress has been shown to have a major negative impact on

 They avoid patient contact.

 They may not give as good patient care.

 Their capacity for caring is strained.

 They leave the profession.

Factors that Confound Ethical Problems include:

1. Uncertainty : The lack of predictability of the outcome of a certain action.

Factors that Confound Ethical Problems include:

power, and social or institutional power (doctors, nurses, patients)

Resolving an ethical problem requires careful deliberation (diligence, vigilance

Giving good reasons for ethical decisions is called moral justification.

1. Assess the situation:

 Operating values in the situation of issue.

Example: assess persons and parties involved, causes, etc…

2. Identify the moral problem you are dealing with: