Ethical Decision Making for the APRN

2015 APRN Spring Conference

Tupelo, Mississippi

Janie Butts, Ph.D., RN Professor, USM

Elizabeth Tinnon, Ph.D., RN, CNE Assistant Professor, USM

The ANA DECLARES 2015 AS the

“YEAR OF ETHICS”

First Nursing Ethics Book Published in 1900

Now, however, not only as

individuals, but as a profession,

we are beginning to feel an

increasing necessity for some such

definite moral force or laws that shall

bind us more closely together in this

work of nursing, and that will bring us into

more uniform and harmonious relations.

(Elizabeth Hampton Robb, 1900)

Ethics Defined

“What should I do?”

“How ought I act?’• Various ways of understanding and examining

the moral life Beauchamp & Childress (2012)

• Is a systematic approach to understanding, analyzing, and distinguishing matters of right and wrong, good and bad, and admirable and deplorable as they relate to human beings, relationships and professional decisions Butts & Rich (2016)

What is an Ethical Dilemma• A situation where at least two equally justifiable

desirable courses of actions OR two equally undesirable courses of action in which a person is uncertain which one to choose

• A dilemma results in nurses having to analyze the dilemma and come to a resolution for the benefit of the patient, often based on a benefit-risk proportionality

• A dilemma may require a team effort from the doctor, advanced practice nurse, patients and families, and possibly an ethics committee at the facility

?

Confidence & Knowledge: Research Findings

• Knowledge 27 multiple item ethics knowledge exam

Average score 55%

• Confidence Recognize genuine ethical problem

4.26 (Likert 1-5) Reach sound decision when facing problems

3.86 (Likert 1-5) Give reasons for your decision

3.83 (Likert 1-5) Laabs, C. (2012)

Bioethics

Definition of Bioethics

Every day ethical issues that are raised by real everyday problems of health and illness, which may include medical and nursing ethics, life and death ethics, population ethics, animal ethics, and environmental ethics.

Bioethics (cont’d.)

Doing Ethics,

Doing BioethicsDoing Ethics emphasizes that moral decision-making is an active process.

The “doing” is the process by which we analyze issues in order to come to a decision.

The Birth of Bioethics1947 -1987

The horrific treatment of human beings during World War II by Hitler’s Nazi SS in concentration camps and by indoctrinated doctors and nurses conducting experiments “in the name of research” led to the Nuremberg Trials of 1947.

The Birth of Bioethics (cont’d.)

1947 -1987

The Nuremberg Code of 1947 to protect humans was created based on the worldwide belief that we would never again allow this inhumane treatment.

Later followed: WMA Declaration of Helsinki in 1964 and U. S. Belmont Report in 1978.

Today, every organization and university worldwide has a federally-mandated IRB committee to oversee the protection of human subjects.

The Birth of Bioethics (cont’d.)

1947 -1987

• Childress served on the President’s Council of Bioethics in the 1970s

• Council resulting from rationing of organs and increasing technology

• First edition of Beauchamp & Childress of Principle's of Biomedical Ethics in 1979 and now in its 7th edition as of 2012

The Birth of Bioethics (cont’d.)

1947 -1987

“Who’s going to pay?”

“How do we

choose?”

“Who shall die?”

“Who

shall

live?”

“Do we ration organs

and health care?”

Moral Principles

• Respect for autonomy

• Non-maleficence

• Beneficence

• Justice

Beauchamp & Childress

(1979; 2012)

Virtue EthicsAristotle

• Two sorts of virtues: Intellect and character

• Virtues are developed by character and habitual practice, which is called practical wisdom

• Without having practical wisdom one cannot have excellence in character

• Known also as character ethics

A virtuous person will act virtuously.

Virtue Ethics (cont’d.)

• The concept of virtue is ancient, durable, and pervasive in the whole history of ethical theory.

• The cardinal virtues are:

Wisdom, courage, temperance, justice, generosity, faith, hope, and charity

• The contemporary virtues are:

Honesty, compassion, caring, responsibility, integrity, discernment, trustworthiness, and prudence.

Nursing Ethics

The examination of all kinds of ethical and bioethical issues from the perspective of nursing theory and practice, which in turn rest on the agreed core concepts of nursing, namely; person culture/care, health healing, environment and nursing itself.

Johnstone (2008, p. 16)

Examples of Ethical Dilemmas

• Privacy and confidentiality

• Health care fraud

• Boundaries and respect

• Social media and behavior

Ethical Decision Making Analysis Models

• Four Topic Method of Ethical Analysisby Jonsen, Siegler, Winslade

• Moral Decision Making Modelby Megan-Jane Johnstone

Medical IndicationsBeneficence & Nonmaleficence•Med problem, hx, diag, prog•Status, acute, chronic, etc•Goals of tx•Probability of success•What if, therapeutic failure•Benefits, and harm avoided

Patient PreferencesRespect for AutonomyMentally capablePatient’s preferenceRisks, benefits, informed consentIncompetent/ surrogatePatient’s preferences priorIs the patient willingIs the patient’s rights being respected

Quality of LifeBeneficence & Nonmaleficence & Respect for AutonomyProspects for return to normalAre there any likely deficits r/t TxBiases presentCould life be judged undesirablePlan to forgo treatmentPlans for comfort/ palliative care

Contextual FeaturesPrinciples of Loyalty/Fairness Family issues that might affect txProvider issues that might affect txFinancial and economic factorsReligious/ cultural factorsLimits on confidentialityAllocation of resourcesLegal/conflict of interest with parties

Four Topics Method of Ethical Analysis by Jonsen, Siegler, Winslade

by Megan-Jane Johnstone

An Ethical Dilemma Case for You

References

American Nurses Association. (2015). Code of ethics with interpretive statements. Silver Spring, MD: Author.

Beauchamp, T., & Childress, R. (2012). Principles of biomedical ethics (7th ed.). New York: Oxford University Press.

Butts, J. B., & Rich, K. L. (2016). Nursing ethics: Across the curriculum and into practice (4th ed.). Burlington, MA: Jones & Bartlett Learning.

Cameron, A. (2011). Impermeable boundaries? Developments in professional and inter-professional practice. Journal of Interprofessional Care, 25, 53-58.

References (cont’d.)

Chism, L. A. (2016). The doctor of nursing practice (3rd ed.). Burlington, MA: Jones & Bartlett Learning.

Fowler, M. D. (2015). Guide to the code of ethics with interpretive statements. Silver Spring, MD: ANA.

Grace, P. (2014). Nursing ethics and professional responsibility: In advanced practice (2nd ed.). Burlington, MA: Jones & Bartlett Learning.

Griffith, R. (2013). Professional boundaries in the nurse-patient relationship. British Journal of Nursing, 22(18), 1087-1088.

References (cont’d.)Johnstone, M.-J. (2008). Bioethics: A nursing perspective (5th ed.). London Churchill Livingstone.

Jonsen, A. , Siegler, M. & Winslade, J. (2010). Clinical ethics: A practical approach to ethical decisions in clinical medicine (7th ed.). New York: McGraw-Hill.

Laabs, C. (2012). Confidence and knowledge regarding ethics among advanced practice nurses. Nursing Education Perspectives, 33(1), 10-14.

Ulrich, C. M., Danis, M., Ratcliffe, S. J. et al. (2006). Ethical conflict in nurse practitioners and physician assistants in managed care. Nursing Research, 55(6), 391-401.