REQUIRED CRITERIA FOR COMPLETION OF ASSIGNMENTS AND EVALUATIONS:  

*SEE COURSE CALENDAR FOR ALL DATES REGARDING ASSIGNMENTS OR EVALUATIONS.
*ALL ASSIGNMENTS MUST BE TYPED  (responses to multiple choice questions may be handwritten when an answer sheet is provided).  
*DIRECT ALL QUESTIONS AND COMPLETIONS OF ASSIGNMENTS TO  jcooke@muw.edu or fax to 662-844-1927 (modified distance                     students may bring completed assignments to class).
*ALL ASSIGNMENTS SENT VIA EMAIL MUST BE SENT VIA ATTACHMENT.  DO NOT SEND THE COMPLETED ASSIGNMENT
       AS PART OF THE EMAIL MESSAGE, IT MUST BE AN ATTACHMENT.

*REQUIRED WRITTEN ASSIGNMENTS AND EVALUATIONS ARE INDICATED WITH THIS GIF.  
*ADDRESS ALL QUESTIONS OR CLARIFICATIONS TO Jolyn M. Cooke, 662-620-5389.

References:
Kearney, Rose. Advancing Your Career: Concepts of Professional Nursing (2001) 2nd edition, Chapter 14, F.A. Davis Company, Philadelphia.
Marquis, Bessie. Huston, Carol. Leadership Roles and Management Functions in Nursing, (2000) 3rd edition, Chapter 22, Lippincott, Williams and Wilkins,                 Philadelphia.
Zerwekh, JoAnn. Claborn, Jo Carol. Nursing Today: Transition and Trends, (2000) 3rd edition, Chapter 18, W.B. Saunders, Philadelphia. 
http://www.nursingworld.org/ethics/ecode.htm

OBJECTIVES:
By completion of this course and as evidenced by successful completion of evaluation criteria, the student
will be able to:
1.  Define ethics and selected terminology related to ethics.
2.  Examine ethical theories.
3.  Discuss the structure of an ethical dilemma.
4.  Apply critical thinking to analyze ethical problems.
5.  Apply the ethical analysis model to interpret ethical problems.

Think about:
1.  What ethical system do you use when making ethical decisions?  Why?
2.  Recall patient care situations that you experienced where ethical decision making was required.
3.  What is your experience with managed care?  Do you have any personal experiences with limited
        access or do you know of anybody who has experienced limited access to health care?
4.  What are the key ethical issues in restricting access to health care?  Is it right to do so?  How would you
        correct the problem?
5.  Should people who have hurt their health by drinking alcohol, abusing drugs, smoking or overeating have the same
        right to care as people who take care of themselves?
6.  What do people fear most about dying?
 
 

Ethics is a branch of philosophy that is concerned with human conduct. It is the study of the rational process for
determining the best course of action in the face of conflicting choices.

ethics-systematic study of what a person's conduct /actions ought to be with regard to himself, others and the
environment

Ethics attempts to find the answer for each of us to Gibran's question, "How shall I go in peace and without sorrow?" (Gibran ).
Conflicting ethical issues raise two questions for a person:
1.  "How can I find an answer that will allow me to be at peace with myself?" (Personal value system)
2.  "How can I find an answer that will allow me to be at peace with others?" (Possibly conflicting value systems).

To answer the first question, a person tries to determine the degree of congruity between a particular choice of action and their individual perceptions of right and wrong. The criteria used to judge are internal. The analysis is purely subjective.

The answer to the second question is not, however, subjective. It involves either a consideration of the duties one person owes another by virtue of commitments made and roles assumed, or a consideration of the effects that a choice of action could have on the lives of others. Although the consideration of the duty involved may be internal, the criteria utilized to judge are external. In this sense the analysis is objective.

Ethics proposes to identify, organize, examine, and justify human acts by applying certain principles to determine the right thing to do in specific situations. The subject matter of ethics does not involve involuntary human behavior, but human acts chosen freely and intentionally.
 

applied ethics-requires the application of  the normative ethical theory to everyday problems, the normative ethical
    theory for each profession arises from the purpose of the profession (Veatch&Fry, 1987)

Since management is not a discipline, it does not have a defined purpose (like law or medicine) and lacks guidelines
for ethical decision making; therefore, the manager's obligation is tied to the organization's purpose.  Thus, a manager
has a complex set of interactions when dealing with ethical dilemmas.......personal, professional, organizational,
and societal values.

Ethical decision-making is a skill that can be learned like any other skill......the more one practices, the more
proficient one becomes. We face ethical dilemmas daily!!!  They are constant! The troublesome dilemmas
are elevated for committee consideration, usually.
Ethical dilemmas can be patient based or management based......many scenarios are possible involving staff or
patients.

In nursing, the focus has changed from a physician based decision, to more of a patient-based approach.
The last documented ANA Code of Ethics, dated 1985, is presently being revised and a new copy is pending.
 
 

ATTENTION ALL STUDENTS:   MAKE SURE THAT YOU CAN DEFINE THESE TERMS.  THESE
ETHICAL PRINCIPLES WILL BE UTILIZED THROUGHOUT THE ENTIRE CURRICULUM.  SINCE
ALL THE CONTENT IN NU 359 IS FUNDAMENTAL, YOU MUST RETAIN THIS KNOWLEDGE
AND UTILIZE THE CONTENT THOUGHOUT YOUR NURSING COURSES.

1.  Beneficence - the obligation to do good; doing what is good for the patient; considers
        a holistic approach considering the patient's beliefs, feelings and wishes

2.  Nonmaleficence - to do no harm; to refrain from inflicting harm; rather a difficult concept, because
        a healthcare provider may have to "do harm", such as a difficult procedure to prolong the
        patient's life; also, the responsibility to protect vulnerable populations (very strict laws have resulted)

3.  Autonomy - the right to make one's own decisions and to respect the choices others make for themselves
        right of self-determination, independence and freedom; the patient has the right to make his
        own health care decisions, even if the provider does not agree with the decision.  Dilemmas
        occur when others' (the public) health may be affected, such as in the case of a patient's
        refusal to treat an infectious disease which might endanger the public.  The patient may
        be forced into therapy or forced into isolation.

4.  Justice - the obligation to be fair to all people; to treat each person equally; an equal right to
        healthcare; as with other rights, limits can be placed on justice when it interferes with
        the rights of others.  The first statement in the ANA Code of Ethics applies here:
        "The nurse provides services with respect for human dignity and the uniqueness
        of the client unrestricted by considerations of social or economic status, personal
        attributes, or the nature of health problems"  (ANA, 1985)

5.  Fidelity - the obligation to be faithful to the agreements and responsibilities one has undertaken;
        an obligation to be faithful to the commitments made to self and others; concept of
        accountability;  for example, the nurse may experience a conflict when asked to work
        a second shift, so one must weigh fidelity in relation to one's employer or one's
        obligation to others (family)

6.  Veracity - truth telling; truthfulness; never to mislead or deceive a patient; informed consent

7.  Paternalism - one person assumes the authority to make a decision for another; limits freedom
    of choice, most ethical theorists believe paternalism is justified only to prevent harm;  in
    management, the manager assumes to know more about what is best for the employee

8.  Utility-what is best for the common good outweighs what is best for the individual

9.  Futility-refers to medical intervention (beyond comfort care) without realistic hope or
    benefit (improvement) to the patient.......example, continuing ICU care to a  patient
    in a persistent vegetative state
 
 

Different approaches to ethical dilemmas:
-Hippocratic View was approach by MDs.  (patients can never take this view because it basically
        leaves the pt. out of the process)
-Nightingale Pledge was approach used by nurses, more focus on care and compassion.

Now, approaches are based on many things:  nurses and medicine have ethical codes, religions have ethical codes,
professional groups have ethical codes, individual roles have ethics, and then there's the military;
then there is the LAW..........and depending on which code you read, your decision can be
affected....can be very controversial.  Cultural and religious influences!  Insurance companies
are key players!

Members of the same profession can have differing views, because they come from different
religions and cultures.  Common ethics are not shared just because we are all of the same profession.

incommensurable-disproportionate; unequal; in considering ethical dilemmas, values are weighed
    against one another, and the situation becomes incommensurable;  it is difficult to consider
    all the values equally with all the parties concerned
 
 

Identify influences in ethical decision-making for the nurse manager:
-increasing technology
-regulatory pressures
-competitiveness among healthcare providers
-national nursing shortage
-reduced fiscal resources
-spiraling cost of supplies and salaries
-public distrust of hth care institutions (McCloskey and Grace, 1994)
-intrapersonal conflicts (individual beliefs and values, personal philosophy)
-multiple advocacy roles (to pt., staff, admin.)
-accountability to profession
-changes in hth care delivery systems
-decreased personalization of hth care
 
 

ethical dilemmas present problems that defy a simple solution (Catalano, 2000)
basically, an ethical dilemma exist when a simple solution cannot be found

SELF-AWARENESS
Know who you are and what you believe.......vital because it fosters self-initiation, self-correction
and self evaluation........what are your values

NO rules or code cover all the aspects of ethical dilemmas.......only the individual can decide if he acted
within his own belief system.

BE PREPARED to live with some degree of ambiguity and uncertainty.  One wants to investigate and get
as much data as possible, but do not let the uncertainty paralyze decision-making.
Any ethical decision must be considered as uncertain- only a degree of certainty can
and should be obtained.
 

Rarely does one emerge from an ethical dilemma without the lingering questions of "What's
the right thing to do?"  or "Did I do the right thing?"
In an ethical dilemma, the choice is between equally unfavorable alternatives and the people involved
place significance on different value judgments.

CRITICAL THINKING occurs when an orderly process of problem solving to determine right
    or wrong, or identify actions has been achieved.

Must have systematic approach in decision-making regarding ethical  dilemmas:
-focus on proven methods
-avoids errors
-increases probability of success

How does one measure if the right decision has been made?
-What human and fiscal resources were used?
-What were the outcomes ? (even the most ethical decisions yield undesirable or unavoidable consequences)

In measuring, to determine if the best decision was made,  it is best to consider the terms of the
actual process, the extent of data gathering, and the comparison of multiple alternatives.
 

PROBLEM-SOLVING METHODS:
Traditional Problem-Solving Process  (Marquis, p. 482)
1.  identify  the problem
2.  gather data to analyze the causes and consequences of the problem
3.  explore alternative solutions
4.  evaluate the alternatives
5.  select the appropriate solution
6.  implement the solution
7.  evaluate the results

Nursing Process
Assess, diagnose, plan, implement, and evaluate.......a continuous process!

MORAL method - incorporates nsg process and biomedical ethics, especially useful in clarifying ethical problems
    that result from conflicting obligations
M-massage the problem...collect data about the ethical problem and who should be involved in the decision-making
O-outline options, identify alternatives and analyze causes and consequences of each
R-review criteria and resolve, weigh options against the values of those involved in the decision
A-affirm position and act, develop the implementation policy
L-look back, evaluate the decision making

Steps of Ethical Decision Making:  (Kearney)

• collect, analyze, and interpret the data
• state the dilemma
• consider the choices of action
• analyze the advantages and disadvantages of each action
• make the decision

Murphy and Murphy (1976) Approach to Ethical Decision Making
The process does not attempt to solve the underlying problem, but does require decisions,
and helps clarify basic beliefs and values of the people involved.
1.  id the problem
2.  id why the problem is an ethical problem
3.  id the people involved in the ultimate decision
4.  id the role of the decision maker
5.  consider the short- and long-term consequences of each alternative
6.  make the decision
7.  compare the decision with the decision maker's philosophy of ethics
8.  follow up on results of decision to establish baseline for future decision making

ETHICAL FRAMEWORKS FOR DECISION MAKING
The following principles do not solve the ethical problem, but assist the manager in clarifying
personal values and beliefs.  No two ethical dilemmas are the same, but these principles
are commonalities in analyzing ethical dilemmas.

These frameworks could be considered theoretical approaches, also. Remember: theories are
our attempts as human beings to explain how things that cannot be proven, work. If the theory
could be proven, then it would be a fact, not a theory.

Ethical frameworks or theories:

utilitarianism-makes decisions based on what provides the greatest good for the greatest number of people
(using money to fund inservice for large group rather than send one of two on educational trip)
(insurance uses money to fund needs of many and refuses to cover transplants)

deontology-also know as duty-based; ethical decision making based on moral rules and unchanging
principles;  a purist in this theory would make the decision based on the rules, regardless of
the consequences; one determines the rightness of an act based on principles and motives, independent
of the consequences

teleologial-outcome focused and the emphasis is placed on results;  that which is useful is good;
the rightness or wrongness of an act is determined by the results of that action; the end justifies the means

situational-no rules, norms or majority-focused results that must be followed; each situation is unique
and creates its own set of rules

duty-based reasoning-bound by duty

rights-based reasoning-each ind. has basic rights, claims, or entitlements with which there should be no interference;
different from needs, wants or desires

intuitionist framework-each problem considered on case-by-case basis; weighing the goals, duties and rights for that
particular situation; potential for bias and subjectivity

professional code of ethics-set of principles est. by a profession to guide the practitioner; do not have the power of law

normative-universally applicable; the norm

non-normative-deny universal principles exist, although there may be an orderly process for decision making

Veatch:
according to Veatch (Ph.D. from Georgetown)
Four levels of moral discourse in ethical decision-making:
1.  Casuistry
2.  Rules and Regulations  (codes, law, regulatory guidelines)
3.  Normative Ethics
4.  Metaethics

Casuistry-automatic, instincts kick-in, morally correct; familiar issues, commonly addressed;  most of
        the decisions are set aside due to analogies to other cases
Examples:  hospital worker did not take the $5 bill on the bedside table while the pt. was asleep;
        Ca pt. refused trt and chooses to die  (real dilemma when is peds pt. and family is withholding trt
        against MD advice, no longer casuistry, but elevates to normative level)
Rules and Regulations-various codes of ethics which can conflict in meaning; law and ethical codes can
        conflict
Normative Ethics-most of the action is on this level; uses theoretical claims behind the rules and regs; think
        of it as being the norm; uses abstract principles

    3 sub levels:
    1.  virtue theory-manifest in ancient Gk and Roman Catholics; important in nsg and medical ethics;
            traits of good character with courage, compassion and love;
            if consider the Hippocratic oath, then characteristics become purity and holiness (modern AMA code
            differs);
            different characteristics according to the code
     2.   value theory-do good and do no harm; controversial (if you prolong the life of a pt. are you doing
            good or harm?)
            this theory considers what is of intrinsic value-beauty, truth, good hth, etc.
     3.  action theory-what are the principles of morally correct conduct?
            this theory is based on impeccable behavior; this person may leave alot to be desired in virtue, but
            is a very principled ind. that always does the right thing as opposed to having his heart in the
            right place;  in a medical setting, may choose to have this person because his actions are correct,
            and his heart does not rule his head; utility, autonomy and justice are noted

Metaethics- explains basic meaning of ethical claims using reason, moral laws; the highest level and
       most abstract level of decision-making/reasoning
 

Types of Ethical Principles:  (Veatch)
 

	Consequential Principles	Duty-based Principles
Individual	Hippocratic (basically) benefit pt., avoid harm focuses on good consequences for pt. (withhold bad news, no informed  consent, no research) cannot disclose info about pt. that         would be of concern to public traditional physician approach	Respect for Person autonomy, fidelity, veracity avoid killing inform pt. but intervene to comfort and        reduce effects of info protect public hth cost containment
Social	Social Utility maximize aggregates socialized medicine concepts classical utilitarianism	Justice everyone has a fair shot

Best approach is to balance the Duty-based Principle, and this is how most committees work.
Ethics committees have a moral and clinical mandate.

For an Ethics Committee to address both clinical and staffing issues may create conflicts of interest.
 

Read the following case study and decide how you would resolve this ethical dilemma.
CASE STUDY:
Mr. Jones is a 72 yo, retired pharmaceutical rep. dx with metastatic CA, two - four weeks to live.
Being maintained on Demerol and Chlorpromazine.
Hospitalized for fainting spells (thought related to meds), and trying to stabilize meds.
Long-term partial paralysis of left leg for 15 years due to car wreck.
Frequent desire to get out of bed, "get some air", and wander (no danger to others).
Found on floor at 1 am........

Nursing response- close to station, lowered bed, side rails, and instructed to call for assistance

Patient wants freedom to get up at will, willing to take risk (risk to hospital?) and sign a release, son advocates for pt.

Options:
1.  chemical restraints advocated by MD, supports Hippocratic oath, benefit pt. and protect, no doctrine
        of consent, cheap and easy, may not be good for pt's. mental health, not respectful of pt's. autonomy
2.  labor intensive supervision advocated by nursing, shows care and concern and respect, ANA code with
        commitment to pt's health, pt's self determination and public welfare, may create neglect of other pts.
3.  let pt. assume risk-family shares pt. rights view, serves pt.'s mental and social well-being even though conflicts
        with hth risks, only team member not supporting option is by PT

Option #3 chosen.......discovered that at age 5, this pt. was trapped in burning barn and has had a childhood
fear of being trapped by a fire since......

Usually, all agendas are not settled, and compromise is necessary.
 
 

No discussion of ethics is complete without a discussion of human rights. What are they?
Does everyone have them? Of what do they consist?

Definition:
Human Rights - Those items which are a person's due as a member of that society. They are not earned
and exist independently of law or public opinion. Human rights claim an authority higher than the state,
an authority founded on essential and universal need. However, they occur in the context of a culture
and are influenced by the beliefs or value systems of that culture.

In 1875 Disraeli's address to the parliament included the following statement, "The health of the people
is really the foundation upon which all their happiness and all their powers of state depend."

Do people have a right to health? Most of the measures society utilizes to protect health involve
protecting a negative right to health - the right not to have one's health endangered by the
actions of others.
Positive obligations flow from negative rights - regulation of environmental factors which affect health of the
community. This advocacy has helped open the door to consideration of the right to health as a
positive right.

In 1949 the United Nations Assembly branch UNESCO claimed "all persons have a right to a
standard of living adequate to provide for health and well being and the right to food, clothing, housing,
and medical care".  This suggests that persons are entitled to certain services,programs, and goods
in order to maintain or achieve health as a basic human right.

BIOETHICS

Bioethics: ethics as it relates to the health care professions--centered on the welfare of the patient.
This is a relatively new field in medicine, but is growing. It is reality-oriented, well-reasoned, and
centered on the individual patient. The growth of bioethics has been shaped by the growth of
technology and the expansion of health care. Ethical decisions in health care must be based on
established, well- thought out guidelines, not hunches or rules of thumb.
The right choice in a bioethical context --to do the right thing at the right time, for the right reason,
and in the right proportion; this can be very difficult-or even impossible!
 

Why should we be concerned with these questions? Is health care a right? What ethical stance
should we take on this and other matters which impact upon our daily practice.

First, we belong to a profession with a strong professional ethic. This has always
been a part of nursing history. Remember your study of values--both the values you hold dear
and the values of others. If our personal values differ from this professional ethic, we are in
a position of value conflict. This value conflict leads to both personal and professional
ineffectiveness. Many of us have managed to escape this predicament in some regard
because we do not examine why we feel or act in certain ways.

The examination of ethics does not produce a laundry list of right and wrong. Neither is ethics
the policeman in your rearview mirror. The examination of ethical issues serves three functions:
clarification, illumination, and comfort.

We talked earlier about our professional value system..The following is from the preamble to the ANA Code for Nurses..."when making clinical judgments, nurses base their decisions on consideration of consequences
and of universal moral principles, both of which prescribe and justify nursing actions.

" The American Association of Colleges of Nursing (AACN) identifies seven essential values for the professional nurse.
They are altruism (concern for the welfare of others), equality, esthetics (a sense of the beautiful),
freedom, human dignity, justice, and truth. "The nurse guided by these values, attitudes, and
personal qualities, demonstrates ethical professional behavior with patients/clients, colleagues
and others in providing safe humanistic care focused on health and quality of life." The code further
directs the nurse to provide care that is independent of personal values related to the social
status and personal attributes of the client or nature of the illness.

Generally the moral conflicts arising in nursing can be categorized into one of three types:
1. Moral uncertainty - failure of the nurse to recognize the nature of the ethical problem.

2. Moral dilemma - involving a conflict between two or more ethical principles with no
    obvious solution.

3. Moral distress - the conflict between the nurse's knowledge of ethically appropriate
    action and what is actually happening in the situation.

No human being, even a nurse, can hold infallibility as a rational standard. However, you can, and
must hold justifiability as your standard. No one, not even you yourself, can expect more than that
you did the best you could under a particular set of circumstances.

COMMON ETHICAL DILEMMAS:
1.  Access to care-can one afford to go to the doctor and buy medicine? is health care a universal
        right or limited to those who can pay? even under socialized medicine, there will be
        some limitations to health care
        What determines one's access to health care?
        What population groups experience rationing of  health care?
                (elderly, terminally ill, disabled)

2.  Organ transplantation-issues arise regarding selection of recipients; some states require that potential
        donors or families be given this option;  sensitive issues arise when children are involved;  as a nurse,
        one should avoid making statements or giving nonverbal indications of approval or disapproval

3.  End-of-life-decisions-euthanasia generally means a painful or peaceful death....passive is allowing one
        to die without extraordinary intervention.......active is speeding an individual's death through
        some act;  assisted suicide is active euthanasia;  is it ethical to use active euthanasia;
        can be a great deal of controversy with moral, legal and ethical issues

4.  HIV and AIDS-confidentiality a big issue;  not required to report to public hth officials;  can a nurse refuse
        to care for an AIDS patient?  Consider the cost involved.....estimated that it cost $750,000 to care for
        one AIDS pt. from dx to death.

5.  Advance Directives-help facilitate patient's desires when pt. is unable to make decisions;  take
        the form of living wills or durable power of attorney;  ethical issues revolve around client's
        level of knowledge of potential problems.......was the client in good health when making
        the decision?  if one says no life support, what if a car wreck occurs and one needs temporary
        ventilation?

6.  Staffing and Delegation

7.  Cloning and Genetic Manipulation, Artificial Insemination

8.  Abortion
 
 

1.    In order to grasp the terms of the nurse/patient agreement the nurse needs to be aware of he patient's unique nature
(autonomy).  Every patient is a unique personality.  To interact with a patient is to interact with that unique personality.
When a nurse acts as a researcher, an educator, or an administrator, she will not be aware of the unique characteristics of any
individual patient.  She must, however, always be aware of the unique characteristics of patients as patients.  If a nursing action is to be justifiable , it must, directly or indirectly, be an action oriented toward patients.  A nurse who fails to recognize the unique character of her patient fails to honor the nurse/patient agreement.  She fails her responsibility to take justifiable ethical actions.

2.    In order to interact with a patient a nurse must interact with his freedom.  Every action that a patient takes arises from his
freedom.  The precondition of a nurse's interacting with the freedom of a patient is that she recognize and respect his freedom.  A nurse who fails to respect her patient's freedom is not interacting with her patient. She, therefore, fails to honor the agreement she has made with the patient.

3.    In order for a person to interact according to an agreement, he must understand the terms of the agreement.  This
understanding cannot exist unless the relationship between the parties is based on a rational trust, and rational trust cannot exist
unless the relationship is based on veracity.  Except in rare circumstances, a nurse who does not communicate and interact with
her patient on the basis of objective truth violates the agreement she has made with him.

4.    A situation where interaction takes place by agreement, yet one party to the agreement has been coerced , is an impossible situation. If any party to the interaction is coerced, there is no agreement. If an interaction occurs through agreement, then no one is coerced into this interaction.  No party to an interaction based on an agreement agrees to be forced.  No one can agree to be forced.  Wherever there is interaction based on agreement, there is the implicit presumption of the self-ownership ( privacy) of the parties to the agreement.  Any agreement is invalid if it, implicitly or explicitly, denies the self-ownership of one of the parties to the agreement.  It, in effect, leaves one party to the agreement out of the agreement.

5.    Wherever there is an agreement, there is a final purpose of the agreement.  An agreement without a final purpose would be
unintelligible.  It would be an agreement to do nothing, and , therefore, no agreement at all.  Whatever the nature of this final
purpose, the exchange of values that the agreement calls for is beneficent action.  Every agreement, by its nature, calls for
beneficent action.  A nurse who fails to act beneficently toward her patient fails to fulfill the agreement she has with him.

6.    Wherever there is an agreement, there must be fidelity to the agreement.  An agreement that will not be honored is a
contradiction in terms.  No nurse can ever justify an ethical decision or action that violates the implicit agreement she has with her patient.
 
 

Ideas for analyzing an ethical dilemma:
- identify the players involved
- identify alternative courses of actions and potential consequences of each
- what values were evident from the players involved
- make a concise statement describing the ethical problem
- is there a breach of duty involved?  describe
- describe an approach for addressing any ethical dilemma
- in resolution of the problem:
    were decisions supported by resources/references?
    is there clarity in the decision?
    was logical reasoning utilized?
    were legal statues observed?
    was there consideration of the patient and resources available
    what was the nurse's role?

"To be a nurse requires the willing assumption of ethical responsibility in every dimension of
practice.~~~~The nurse enters a partnership of human experience where sharing moments
in time~~some trivial and some dramatic~~leaves its mark forever on each participant.~~~~
The willingness to enter with a patient that predicament which he cannot face alone is an
expression of moral responsibility; the quality of the moral commitment is a measure
of the nurse's excellence."    Myra E. Levine
 
 

EXERCISE 2

NU 359  ETHICS

STUDENT'S NAME________________________________________________________

STUDENT'S ID #__________________________________________________________

DATE___________________________________________________________________

ACTIVITIES:  Read the following situations.  Select TWO of the following situations.
State if you agree or disagree.  Explain your decision based on ethical principles (which are defined in the above notes).

1.  People (or patients) have the right to request assistance in dying from healthcare professionals?

2.  A person has the right to refuse treatment, even if it will hasten his/her death?

3.  If death can be accurately predicted because of the removal of a specific type of life support,
        then this is not withholding or withdrawing treatment, it is assisted dying?

4.  Capital punishment is unethical?

5.  Patients have the right to be told the truth even when the family does not want the
        patient to know?

6.  People have the right to participate in all decisions related to their health?

7.  "Slow" codes are unethical?

8.  Organ donation should be encouraged by health care professionals.

9.  The therapeutic use of marijuana for nausea and pain control should be legalized in
        all states?

10. Severely impaired newborns should be allowed to die since their quality of life is so
        compromised and because their care will cost society so much?

11. Abortion is ethical and abortion decisions are the responsibility of the pregnant woman
        and her physician.

12.  Healthcare is not a right, it is a responsibility?

13.  Contraception is the responsibility of all women?

14.  Amniocentesis should be required as part of prenatal care?

15.  Genetic engineering should be advanced and promoted by federal funding?
 
 

Assignment:  Complete the following exercises.

Student Name______________________________________  Student #___________________________
 
 

1.  Do you think the nursing code of ethics is really useful?  Expand your answer and explain why or why not.
       
 

2.  Certainly , the ethical code for clinical nurses and for nurse managers may conflict, at times. Read the following
        situation and respond to the questions below.

        Maggie C, RN and head nurse of a busy neurological intensive care unit, was reviewing the
        weekend staffing for the unit on a Friday afternoon.  As usual, the unit's nine beds were full with clients
        in various levels of recovery from brain surgery or head injuries.  The staffing on the weekend was
        "short," with only enough staff to safetly care for eight clients.  After a great deal of time reworking
        the schedule, calling nurses on the phone, and trading days off, Magie finally managed to arrange
        sufficient coverage for the unit.
            As Maggie was closing her office for the weekend, Dr. West, a neurosurgeon, approached
        her and related the following situation.  Mrs. P, a 63-year-old client with a brain tumor, had been
        scheduled for surgery 3 days earlier.  She had a very rare blood type that was difficult to match,
        so the surgery was delayed.  Although a few days wait would not likely worsen her condition
        drastically, she had become very anxious when informed about the delay in surgery.  The blood
        bank had just obtained the necessary units for surgery and had informed Dr. West that he could
        now operate on Mrs. p.  Dr. West was wondering if the neuro unit would be able to safely
        care for Mrs. P over the weekend.  This was the only unit in the hospital equipped to
        monitor brain surgery and provide appropriate nursing care for this type client.  The neuro
        step-down unit was also full, so it would be difficult getting a bed to transfer one of the neuro
        unit's clients to "make" a bed for Mrs. P.  Mrs. P would most likely require one-to-one care
        for 18 to 24 hours after surgery. (Aiken & Catalano, pp. 187-188)
 

        A.  What considerations and approaches would differ between a clinical nurse and a nurse
                manager when faced with the following same ethical dilemma?  
        B.  If you are the head nurse (manager), what would be your response to Dr. West
                considering your obligations to the patient, physician and hospital?  Identify
                the ethical principles which guide your decision making.  
        C.  If you are a clinical nurse in this area, involved with direct patient care, how
                would you view this dilemma?  Identify the ethical principles which guide your
                decision making.  
 
 

3.  Complete ONE of the THREE chapter exercises on page 319-320 in Kearney.
       

4.  Select one of the following case studies and answer the questions listed. 
 

The Ethics Committee is consulted and numerous questions and issues are discussed.
If you were the nurse on the committee, how would you respond to the following:
1.   Identify the parties involved in this case study.
2.   At what point did this case become an ethical dilemma?
3.   What questions are to be considered in addressing this case (regarding all the parties involved) ?
4.   Identify ALL the alternatives for action.
5.   What are the pros, cons and potential consequences for each alternative?
6.   Could there be a potential breach of duty in any of these alternatives?  Discuss.
7.   What codes of ethics apply in this case (ANA, AMA, etc.) ?
8.   What legal issues could be a factor?
9.   Identify the values demonstrated by each party or values that could be part of each party's approach to this
        dilemma (consider the concept of incommensurability).
10.  Make a concise statement describing the ethical problem.
11.  Identify specific ethical principles evident in this case, and justify your response (autonomy, beneficence, etc.).
12.  How does the concept of "futility" INFLUENCE decision making?
13.  Describe an approach for dealing with this ethical dilemma.
14.  What are the nurse's roles in this case?
15.  If you had the ultimate decision, what would you do to solve this dilemma?
 

CASE STUDY #1:
Mr. Smith  is a retired 72 yo black male, widowed  for six years.
His diagnosis is End stage renal disease and he has been on dialysis for four years.
Religion-Jehovah's witness
Mr. Lane is hospitalized and has experienced cardiac arrest several times and needs a blood transfusion.
The patient refuses the transfusions, and the physician anticipates repeated events of cardiac arrest
        considering Mr. Lane's condition and refusal of the transfusions.
Mr. Lane's desire is to continue CPR as needed and he has declined a DNR option, even though
        his physician has thoroughly explained the patient's options and prognosis. Mr. Lane is not
        opting to extend his life because he is expecting family to arrive or has unfinished business.
        There is no reason, outside of the patient's request, to continue CPR.
Upon refusal of the transfusions, the physician wants to withdraw from the case, but no other
        physician will take the case.
The nursing staff is extending all efforts to comply with the patient's needs, exhausting staff
        and resources.

CASE STUDY #2:
An infant is born with short bowel syndrome and other genetic anomalies.
The parents are fundamental Catholics.Decisions need to be made regarding surgeries and other interventions, and the physician
        has indicated to the parents that the baby has a poor prognosis regardless of the interventions;
        in fact, the physician is concerned about the surgical risks.
The physician explains to the parents, all the available interventions, the risks, the baby's
        prognosis, and that consent is required by the parents to surgically intervene.
The parents tell the physician that they need some time to decide, so they retreat from
        the NICU for a time, and upon their return to the NICU, inform the physician
        that after prayerful consideration, that they feel the baby should be with God.
The parents refuse to consent for surgical intervention or other heroic measures,
        and in addition, want to forego all hydration and nutrition.
The physician and nursing staff understand the parent's decision not to consent to surgery
        and heroic measures, but are extremely uncomfortable with the thought of
        withholding hydration and nutrition.  The parents have promised no legal action
        will be taken if their requests are honored.

ETHICS TEST 

Student’s Name_________________________________________  ID #______________

1. Ethics can be defined as a study of:

 a. what our conduct and actions should be
 b. how people make decisions that are legally and morally appropriate
 c. what our lives and relationships are in reality
 d. conflict, power, and interdependency

 2. Ethical dilemmas:

 a. can be solved using empirical data
 b. have clearly delineated facts for decision making
 c. require choosing between equally undesirable alternatives
 d. should consistently have a good outcome

3. The practice of allocating organs for transplantation based on a person’s “worth to society” is  an example of what ethical principle for decision making?

 a. autonomy
 b. beneficence
 c. paternalism
 d. justice

 4. John Doe has advanced cancer. The only treatment alternative left for him is a rare, highly
experimental bone marrow transfusion with a 10% success rate. His insurance company refused to authorize payment for the $200,000 procedure, arguing that the money could be better spent providing well baby screening for 2000 residents in the service area. This allocation of resources reflects which ethical principle for decision making?

 a. autonomy
 b. non-malfeasance
 c. paternalism
 d. utility

 5. The MORAL model:

 a. is a problem-solving model
 b. does not include an evaluation step
 c. requires the identification and analysis of multiple alternatives for action
 d. requires the involvement of only the decision maker

6. The nurse who agrees to go into work for an emergency disaster drill, despite having company over for dinner, is probably using which ethical framework to guide decision making?

 a. utilitarianism
 b. duty based
 c. rights based
 d. intuitionism

 7. The American Nurses Association Code of Ethics and Interpretive Statements:

 a. outlines minimum levels of ethical behavior that nurses must maintain
 b. functions as a guide to the highest standards of ethical practice for nurses
 c. is a legally binding document
 d. mandates ethical behavior prerequisite for nursing licensure

 8. Decision makers should:

 a. Use outcome as the sole criterion for evaluating ethical decision making.
 b. Identify only desirable alternatives in solving ethical dilemmas.
 c. Make critical ethical decisions quickly so the situation does not become worse.
 d. Accept that some ambiguity and uncertainty are a part of ethical decision making.

 9. Which of the following ethical frameworks does not represent a deontological theory?

 a. duty based
 b. rights based
 c. utilitarian
 d. intuitionist

10. The Murphy and Murphy approach to ethical decision making:

 a. ends with problem identification
 b. ends with making a decision
 c. requires personal analysis of the decision maker’s ethical philosophy
 d. can be used only for group problem solving

11. Which of the following reflects the most accurate statement regarding the major
 responsibility of a manager in advocacy?

 a. Advocacy is a management function and not a leadership role.
 b. Managers should advocate first for their organization.
 c. Managers should advocate for patients as well as subordinates.
 d. Professional advocacy is not a concern for most managers.

12. Autonomy is the moral principle governing:

 a. a person’s right to make his or her own decision
 b. truth telling
 c. the obligation to do good and prevent harm
 d. what is right and fair

13. Protecting patient confidentiality respects the client’s right to

 a. self-esteem
 b. self-defense
 c. self-determination
 d. self-incrimination
 
  Match the following terms with the definitions:

 14.______Beneficence                               A.  medical intervention without hope of benefit

 15.______Nonmaleficence                          B.  the obligation to be fair to all people

 16.______Autonomy                                  C.  truthfulness

 17.______Justice                                        D.  when one assumes authority to make another's decisions

 18.______Fidelity                                        E.  disproportionate

 19.______Veracity                                     F.  to do no harm

 20.______Paternalism                                G.  the obligation to do good

 21.______Utility                                          H.  the right to make one's own decision

 22.______Futility                                        I.  the best for the common good

 23. _____Incommensurable                        J.  the obligation to be faithful

 24._____Deontology                                 K.  no rules approach to decison making

 25._____Telelogical                                   L.  universally acceptable

 26._____Situational                                   M.  duty-based theory

 27._____Normative                                   N.  outcome focused approach
 

Revised
June 2001
Aug 2003