What Would You Do? A Case Study in Ethics

Jeanie Krause-Bachand, Ed. D., RNYork College of Pennsylvania

Ethics and Ethical Dilemmas

• Ethics – involves the principles or assumptions underpinning the way individuals or groups ought to conduct themselves.

• Ethical dilemma – a situation where a choice needs to be made involving options that a person believes can be accepted and justified as moral or there is not a more appropriate choice in that situation.

Ethical Principles

• Autonomy – the right to chose what will happen to one’s self.

• Beneficence – one’s actions should promote good.

• Nonmaleficence – one should do no harm.

• Veracity – persons should tell the truth.

• Fidelity – maintaining one’s promises and commitments.

• Paternalism – decisions are made by someone other then the patient or DPA.

• Justice – fair and equal treatment.• Respect for Others – the right of

persons to make decisions and to live or die based on their decisions.

Ethical Theories

• Utilitarianism– Utility makes an action right or wrong and useful

actions bring about the greatest good for the greatest number of people. The usefulness of an action is determined by the happiness that it creates.

• Deontology– The person’s good intentions will determine the

worthiness of the action. Centers on the norms and rules owed to another person by virtue of the commitments made and roles assumed.

• Principalism– Incorporates existing ethical principles to resolve

conflicts. The use of ethical principles as the basis for professional decision making.

Code of Ethics for Nurses with Interpretive Statements

• 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.

• The nurse's primary commitment is to the patient, whether an individual, family, group, or community.

• The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.

• The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient care.

• The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.

American Nurses Association

• The nurse participates in establishing, maintaining, and improving healthcare environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.

• The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.

• The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs.

• The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.

American Nurses Association, Code of Ethics for Nurses with Interpretive Statements, © 2001 By American Nurses Association

MORAL Model

• Orderly, systematic, and objective ethical decision making process.

Thiroux (1977) & Halloran (1982)

M-Massage the dilemma

• Identify and define the issues.• Consider the opinions of the patient, family

members, nurses, physicians, clergy, other health care team members as well as their values.

O-Outline the options

• Review all options including the less realistic and opposing ones.

• Identity and list all the pros and cons of the options.

R-Resolve the dilemma

• Apply ethical principles to each option.• Select the best option based on the

perspectives of all concerned.

A-Act by applying the chosen option

• Most difficult as it requires actual implementation of the decision.

• Involves more then just dialogue and discussion.

L-Look back and evaluate the process

• Ensure that those involved are on board with the decision and are willing to follow through on the final option.

• If that is not the case, request a second decision and begin the process over from the beginning.

Case Study

Palliative Sedation

• Palliative sedation: The monitored use of medications (sedatives, barbiturates, neuroleptics, hypnotics, benzodiazepines or anesthetic medication) to relieve refractory and unendurable physical, spiritual, and/or psychosocial distress for patients with a terminal diagnosis, by inducing varied degrees of unconsciousness. The purpose of the medication(s) is to provide comfort and relieve suffering and not to hasten death.

Concept of Double Effect

• Concept of Double Effect - when an action intended to have a good effect can achieve this effect only at the risk of producing a harmful/bad effect, then this action is ethically permissible.

Doctrine of Double Effect is applicable if: The action is good itself The intention is solely to produce the good effect The good effect is not achieved through the bad

effect There is sufficient reason to permit the bad effect

Principle of Proportionality

• Principle of Proportionality - death with palliative sedation is foreseen, but the sedation itself is not causing the death of the patient.

Proportionality is relevant based on :• The terminal condition of the patient• The urgent need to relieve suffering• The consent of the patient or healthcare proxy

Ethical Principles

Ethical Theory

Code of Ethics

MORAL Model