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NURSING ETHICS

I. 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.
Background
The onset of nursing ethics can be traced back to the late 19th century. At that time, it was thought that ethics involved virtues such
as physician loyalty, high moral character, and obedience. Since that early time, the nursing profession has evolved, and nurses are now
part of the healthcare team and are patient advocates. The first formal Code of Ethics to guide the nursing profession was developed in the
1950’s. Developed and published by the ANA, it guides nurses in their daily practice and sets primary goals and values for the profession. Its
function is to provide a succinct statement of the ethical obligations and duties of every individual who enters the nursing profession. It
provides a nonnegotiable ethical standard and is an expression of nursing’s own understanding of its commitment to society. The Code of
Ethics has been revised over time. The current version represents advances in technology, societal changes, expansion of nursing practice
into advanced practice roles, research, education, health policy, and administration, and builds and maintains healthy work environments.

I. Virtue Ethics, Teleological Ethics, and Deontological Ethics

Moral reasoning

Moral reasoning is a thinking process with the objective of determining whether an idea is right or wrong. To know whether something is
"right" or "wrong" one must first know what that something is intended to accomplish.

Schools of Thought in Ethics


Virtue Ethics (Ontological Ethics) Teleological Ethics Deontological Ethics
-concerned with the person or character -actions being right or wrong
-emphasizes development through -only look at the rules or consequences of something to decide whether if it is right or
habitual virtuous behaviors wrong
-there is a “supreme aim” that is internal -E.g. Utilitarianism- it emphasizes the -E.g. Kant’s categorical imperative-
and inherently good, and cannot be importance of consequences. i.e. how universal principles concerned with
validated by anything or anyone besides many people are made happy by a intention, not outcome
yourself, and can only be judged by certain action or inaction, and therefore
whether you achieve “eudemonia” or whether this action should happen
human flourishing.
-utilitarian school of ethical thought
states that the end goal justifies the -Deontology is the ethical school of
means even when the means are not thought that requires that both the
moral. means and the end goal must be moral
and ethical

It doesn’t judge actions as right or wrong -Focus entirely on actions which a person performs
but rather the character of the person -deontic/ action-based theories of morality
doing the actions. The person, in turn, -when actions are judged morally right -when actions are judged morally right
makes moral decisions based upon based upon their consequences based upon how well they conform to
which actions would make one a good -“consequentialist ethical theory” some set of duties
person.
What sort of person should I be? “What should I do?”
Develop good character traits Consequences of your choices Follow the rules and your duties
Virtue- based ethical theories place Teleological moral systems are Deontological moral systems are
much less emphasis on which rules characterized primarily by a focus on the characterized primarily by a focus on
people should follow and instead focus consequences which any action might adherence to independent moral rules or
on helping people develop good have. In order to make correct moral duties. In order to make the correct
character traits such as kindness and choices, you have to make some moral choices, you simply have to
generosity. These character traits will in understanding of what will result from understand what moral duties are and
turn allow a person to make the correct your choices. When you make choices, what correct rules exist which regulate
decisions later on in life. Virtue theorists which result in the correct these duties. When you follow your duty,
also emphasize the need for people to consequences, then you are acting you are behaving morally. Otherwise,
learn how to break bad habits of morally. Otherwise, you are acting you are behaving immorally.
character, like greed or anger. These are immorally. The problem comes in
called vices and stand in the way of determining correct consequences when
becoming a good person. an action can produce a variety of
outcomes. Also, there may be a
tendency to adopt an attitude of the end
justifying the means.

II. Divine Ethics/ Divine Command Ethics

Based on the theory that there is a Supreme or Divine being that sets down the rules to provide guidance to moral decisions. For Christians,
these rules are found in the Ten Commandments Example – A nurse is approached by her friend who request for an abortion. The nurse
refuses but refers the friend to a doctor who can perform it. This is a violation of the divine command, “Thou shall not kill.”

We strive to become moral because God is good and He commands it to us to be also good.

The theory asserts that good actions are morally good as a result of their being commanded by God, and many religious believers subscribe
to some form of divine command theory. Because of these premises, adherents believe that moral obligation is obedience to
God's commands; what is morally right is what God desires.

III. Key ethical principles in nursing

A. Autonomy

“The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every
individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.”

Autonomy is the notion that competent adults have the right of self- determination and this right should be respected by health care
providers. Many ethicists consider autonomy to be the major overriding bioethical principle (Fry and Veatch, 2006). That is, adults have the
right to decide what health care they want, as well as when, how and who will be involved in that care. It is taken for granted by most that no
competent adult can be forced to have surgery or to undergo treatment if they do not want to do so. In fact, the ideal of autonomy posits that
adults do not even have to seek care. In reality, the concept of autonomy is not so absolute. Tuberculosis patients can be forced into care if
they are contagious, and soldiers can be forced to be immunized.

B. Veracity

Another guiding ethical principle is that of veracity, or truth-telling. Truth is a difficult concept because there is little that is known to be
absolutely true. Truth telling and its opposite, lying, are the center of a long history of debate. Many, but not all of the early philosophers,
including Augustine and Aquinas, saw lying as a moral wrong and truth telling as the moral right (Bok, 1978). Later, Kant would say that there
are no circumstances under which lying was acceptable (Kant, 1993). This would seem to be a statement with which many would initially
agree. Yet there may be times when individuals lie and see it to be a moral good. In a famous example it is posed to the reader that if you
were hiding an innocent person in your house and a murderer came to the door, would you be justified in lying to the murderer? Many would
argue that in this case, the lie was justified. Yet Kant would have disagreed. While extreme, this example demonstrates that an absolute
statement against lying, or for truth telling, is not always desirable. It appears that not all lies are created equal, for as Grotius described it,
an unacceptable lie is only the one that causes harm or violation of rights (Bok, 1978).

C. Beneficence

According to Beauchamp (2008), the word ‘beneficence’ implies mercy, kindness and charity. While beneficence is the act, the moral virtue is
benevolence. Many philosophers have explored what beneficence means in life. The philosopher David Hume (Morris, 2009) thought that
beneficence was a central principle of human goodness, while Kant saw it as a duty (Kant, 1998). More recently, Beauchamp and Childress
(2008) wrote of two aspects of this principle—positive beneficence and utility beneficence—both of which are important to bioethics.

Positive beneficence refers to the principle that individuals have positive obligations to others (Beauchamp and Childress, 2008).
Beauchamp and Childress give examples of positive beneficence, including rescuing people in danger, helping people with disabilities and
so forth. They refer to these as moral rules of obligation.
There has been much recent discussion about moral obligations and how far they extend (Scheffler, 1997). In general terms, it appears that
individuals feel more obligated to those with whom they are close in terms of friendship, kinship or proximity and less obligation is felt to
those further away (Murphy, 1993). Some modern philosophers see this as wrong and write that our concern should be for every human
soul, not just the ones we may know (Singer, 1972; 1999). Singer is a strong advocate for the general obligation of beneficence—to do what
is good no matter our relationship. Other writers speak of situational or specific beneficence where one’s obligation is only to those known
(Murphy, 1993). There may be limits to our obligation to be beneficent. No one has the perfect gift of time, money, strength, and compassion
to meet all needs, yet that is what beneficence would ideally have us do.

We all want health care providers to do good and contribute to the overall welfare of patients. Within the professional nursing role there is an
obligation, a duty to provide care. This also implies there is a duty to beneficence, although this is not directly stated in the ANA Code of
Ethics. In part, the duty of beneficence is a reflection of reciprocity (Rawls, 1971). Nurses are paid to care, or at least to provide care, thus
illustrating reciprocity. Within that arrangement, care is the unspoken obligation to work towards the welfare of the patient. The social con-
tract between patient and nurse is one that is focused on what is best for the patient, both because it is a paid obligation but also because it
is a professional and societal expectation.

The utility of beneficence is that the resultant good should outweigh the bad in all ethically-based decisions (Beauchamp and Childress,
2008). Many decisions in health care are firmly situated within utilitarianism, especially those of public health. For example, immunizations
greatly benefit the whole population but still may entail harm to individuals. Every year a handful of people have bad outcomes (including
death) from basic immunizations. These results are accepted, in the utilitarian sense, because the good so strongly outweighs the few bad
outcomes. The utility approach is sometimes difficult, as the individual is not considered except as part of the whole.

Peirce and Ekhardt write of their ethical concerns (unpublished manuscript) with the wholesale acceptance of evidence-based practice.
Evidence-based practice is predicated on the view that one treatment, one medication and so forth is good for all, yet it may not be. Rather,
evidence-based practice is good for the average and not for the outlier. Thus utilitarianism principles may override the rights of the individual
in order to care for the whole. Because nursing’s mandate has always been the care of the individual, there may be ethical issues for some
compulsory aspects of evidence-based practice.

Paternalism may come into play with beneficence. Beneficence carries the “odor” of paternalism, in that health care providers sometimes
use their own judgment to do what they believe is best for those who are ill or infirm, perhaps overriding the patients’ preferences or failing to
ascertain the preferences. There are no set rules for who decides what is good and what benchmarks are used for these decisions. There
have been instances in the not too distant past in which women were sterilized without consent because the physician thought it wise
(ACOG, 2007; Zumpano-Canto, 1996).

However, paternalism is not always problematic. Sometimes input cannot be obtained and then paternalism can make the difference
between a good outcome and a bad one. Paternalistic decisions are made frequently in emergency rooms and surgical suites as well as in
times of natural and man-made disasters. At those times, it is desirable for a knowledgeable person to take charge and make decisions.
While some- one has to make decisions in times of crisis, it is hoped that the decision is in the best interest of those affected.

Beauchamp and Childress (2008) propose that while beneficence may be the goal, paternalism is sometimes needed. Paternalism is used to
justify both beneficence and nonmaleficence. They list the four criteria that must be met before paternalism can be justified as follows: 1.
The patient is at risk for significant preventable harm. 2. The paternalistic act will probably prevent the harm. 3. The benefits of the act
outweigh the risk to the patient. 4. The least restrictive act is followed.

D. Non-maleficence

Nonmaleficence is distinguished by active, intentional actions that prevent the infliction of harm. To “not do harm” is viewed as separate from
preventing harm or promoting good, both of which are generally labeled beneficence (Armstrong, 2007). Many ethicists write that the
obligation to not cause or prevent harm is more important, “more stringent”, to quote Beauchamp and Childress (2001) than the obligation to
do good.

The distinction between these clearly overlapping concepts of pre- venting harm and promoting good are difficult for many to distinguish.
Similar to Frankana’s arguments (1988), it can be posited that there is a continuum over which these acts occur. At one end is the obvious
intention to do harm solely for the sake of harm and on the other, the obvious intention to do good solely for the sake of good. In between
there are acts—intentional or not—which promote the motion towards one end or another. Immunizing a child is done for good, both for the
child and for the herd immunity it promotes. Yet this act also carries within it harm; at minimum it hurts and upsets the child, at maximum it
leads to death. At the adult level, nurses who work in hospitals may be required to receive booster immunizations. This is done not on the
volition of the individual, but as a mandate from the system. Is this a matter of nonmaleficence, of doing no harm, or of beneficence, the
promotion of good and how does it relate to autonomy and justice? The answer varies as the viewpoint changes from person to system.
E. Justice

Justice has many definitions, but at its simplest, it is the act of being fair. Hume pointed out that it is only when there is a scarcity of
resources, is justice questioned (Cohen, 2010). We all want what is fair, or our fair share of limited resources, whether it is food, fuel or
health care. Jus- tice is also the punishment that is meted out when fairness is breached.

Fair allocation of scarce resources seems to be a Natural Law as it seems instinctive in humans and even some animals (Murphy, 2011). We
instinctively respond to the idea that all are accorded what is due to them. There are no simple answers to questions of justice and it is
difficult to fairly allocate resources (distributive justice) and yet reconcile the common and individual good (commutative justice).

The principle (and the virtue) of justice requires health care decisions to be fair and equal (Fry and Veatch, 2006). Americans have come to
expect that all have the same rights when it comes to access to care, the provision of care and that health care be fairly distributed. All of
this, of course, may not be true but rather it is the ideal. Allocation of limited resources poses many real as well as potential dilemmas in
health care. Recently there have been debates as to how scarce influenza vaccine reserves might be allocated in a pandemic influenza
outbreak. Various solutions have been discussed including vaccination of all first line providers, distribution based upon age, or even random
distribution through a lottery. In each case, the choice to make the vaccine avail- able to one group would mean that others would not have
access to the resource. A system based upon immunizing the caregivers first might ensure better health care for the sick; a system based
upon a national lottery would ensure fair distribution across all constituencies. Immunizing caregivers suggests utilitarianism as regulators
look at the con- sequences of an act designed to care for as many of the sick as possible. The lottery system involves distributive justice, or
the equitable allocation of resources among people. In either case, there will be devastating consequences for some but not for all.

Philosophers have begun to develop the concept of capability as a way of exploring social justice as well as beneficence. Capability theory
proposes that the achievement of well-being is the primary moral driver, and that to achieve well-being it is necessary to foster an individual’s
capabilities (Nussbaum, 2003; Sen, 2005). Nussbaum delineated ten capabilities that are important to consider when there are questions of
social justice. They include:

1. Having a normal, expected life span.

2. Being able to have good health and the elements that contribute to it, such as food and shelter.

3. To be secure in movement and other abilities, such as reproductive choice.

4. To be able to think, reason and imagine.

5. To be emotionally connected.

6. To have practical reason in order to critically evaluate one’s life.

7. To have the ability to affiliate with others.

8. To live with and have concern for the earth, its animals and plants.

9. To be able to play and enjoy life.

10. To be able to control one’s environment through political participation and property rights.

To achieve justice within this framework, it is necessary to promote acts that help achieve these ten capabilities. Many of the capabilities
proposed by Nussbaum echo the nursing literature’s emphasis of the bio-psycho-social care of the individual (Smeltzer, Bare, Hinkle and
Cheever, 2010). As a result, nurses make justice-based decisions daily, from triage in the emergency room to who receives the first or most
care during a shift or in a clinic.

F. Confidentiality

Confidentiality protects patient’s privileged information and guards a care provider’s trustworthiness. Patients surrender some privacy by
divulging privileged information to a health care provider. It is important to note that in this process, they do not surrender control over how
the information is used. Confidentiality obligates the provider to not share privileged information without permission from the patient. Trust is
weakened if the patient fears unauthorized disclosure and will impede the provider’s ability to care for the patient.