Ethical Issues
Differences between Morals and Ethics
Morals are the “shoulds,” “should nots,” “oughts,” and “ought nots” of actions and behaviors, and they are related closely to cultural and religious values and beliefs that govern our social interactions. Morals form the basis for action and provide a framework for the evaluation of behavior.1
Ethics are concerned with the basis of the action rather than whether the action is right or wrong, good or bad. Imposition of ethics implies that an evaluation is being made that is based on or derived from a set of standards. It refers to what rules are required to prevent harm to persons and to the collective beliefs and values of a community or profession.1
Moral Distress
Recently, moral distress has been a topic widely discussed in the literature as a serious problem for nurses.2–5 Nurses face multiple challenges on a daily basis: emergency situations, tension from conflict with others, complex clinical cases, new technologies, increasing regulatory requirements, acquisition of new skills/knowledge, staffing issues, financial constraints, workplace violence, to name a few. This care environment has led to increasingly complex moral and ethical dilemmas.5 In addition, they frequently may experience emotional outbursts from patients, families, co-workers, and feel a lack of control and “burnt out.”2,5 Moral distress occurs when a person knows the ethically appropriate action to take but cannot act on it. It also manifests when a nurse acts in a manner contrary to personal and professional values. As a result, there can be significant emotional and physical stress that leads to feelings of loss of personal integrity and dissatisfaction with the work environment. Relationships with co-workers and patients are affected, and the quality of care can be negatively affected. There is also a great impact on personal relationships and family life; nurses experiencing moral distress may resign their position or leave the profession entirely.3
It is therefore important that nurses recognize moral distress and actively seek strategies to address the issue through institutional, personal, and professional organizational resources. Knowledge and application of ethical principles and guidelines can assist the nurse in daily practice when ethical dilemmas occur. Box 2-1 provides a position statement on moral distress, promulgated by the American Association of Critical-Care Nurses (AACN).6 The document is evidence-based, providing additional references for the reader. There is also a reference to ensuring that support to alleviate moral distress is present in a healthy work environment (see Chapter 1). Actions are listed for direct care staff nurses as well as employers.
The AACN has created a framework—The 4A’s to Rise Above Moral Distress—to support nurses who are experiencing moral distress (Figure 2-1). ASK, the first stage, is a self-awareness and reflection period in which one becomes more aware of the distress and its effects on oneself. Specific areas to address are physical, spiritual, emotional, and behavioral responses. During stage two, AFFIRM, one affirms the distress and makes a commitment to take care of oneself. In stage three, ASSESS, one needs to identify the timing and context of when the stressors occur; determine the severity of the distress; and examine one’s readiness to act. The final stage, ACT, consists of preparation, the action itself, and maintaining the desired change. Although the model was created by AACN, it is a framework that can be used in diverse settings and by various health care professionals.7 McCue8 reported using this model as a resource for resolving an issue between a chief nurse executive and chief executive officer. In this case, the impact of the outcome was at the organizational level.
Moral Courage
In order to avoid moral distress, nurses must feel free to advocate for themselves, their patients, co-workers, and a safe and effective work environment. Lachman and colleagues describes moral courage as “the willingness to stand up for and act according to one’s ethical beliefs when moral principles are threatened, regardless of the perceived or actual risks (such as stress, anxiety, isolation from colleagues, or threats to employment)”.9,p24 They describe organizational cultures that support moral courage, the importance of peer support, education, and policies that can support moral courage of staff. Other authors have reported that moral courage is needed in everyday practice and that one must act ethically even in the presence of risk.4,10
Ethical Principles
Certain ethical principles were derived from classic ethical theories that are used in health care decision making. Principles are general guidelines that govern conduct, provide a basis for reasoning, and direct actions. The six ethical principles that are discussed in this chapter are autonomy, beneficence, non-maleficence, veracity, fidelity, and justice (Box 2-2).
Autonomy
The concept of autonomy appears in all ancient writings and early Greek philosophy. In health care, autonomy can be defined as an agreement to respect another’s right to self-determine a course of action and the support of independent decision making11 without coercion or interference from others. Autonomy is a freedom of choice or a self-determination that is a basic human right. It can be experienced in all human life events.
The critical care nurse is often “caught in the middle” in ethical situations, and promoting autonomous decision making is one of those situations. As the nurse works closely with patients and families to promote autonomous decision making, another crucial element becomes clear. Patients and families must have all of the information about a particular situation before they can make a decision that is best for them. They should be given all the pertinent information and facts, and they must have a clear understanding of what was presented. This is where the nurse is a most important member of the health care team—as patient advocate, the nurse provides more information as needed, clarifies points, reinforces information, and provides support during the decision-making process. Box 2-3 presents the Nursing Interventions Classification (NIC) feature on nursing intervention activities that facilitate decision making.
Beneficence
The concept of doing good and preventing harm to patients is the sine qua non for the nursing profession. However, the ethical principle of beneficence—which requires a nurse to promote the well-being of patients—points to the importance of this duty for the health care professional. The principle of beneficence presupposes compassion; taking positive action to help others; desire to do good. It is the core principle of patient advocacy.11 Harms and benefits are balanced, leading to positive or beneficial outcomes. In approaching issues related to beneficence, conflict with another principle, that of autonomy, is common. Paternalism exists when the nurse or physician makes a decision for the patient without consulting the patient.
Fidelity
Another ethical principle that is closely related to autonomy and veracity is fidelity. Fidelity, or faithfulness and promise-keeping to patients, is an essential aspect of nursing. The American Nurses Association (ANA) states that this principle requires loyalty, fairness, truthfulness, advocacy, and dedication to our patients. It involves an agreement to keep our promises. Fidelity refers to the concept of keeping a commitment and is based on the virtue of caring.11 It forms a bond between individuals and is the basis of all professional and personal relationships. Regardless of the amount of autonomy that patients have in critical care areas, they still depend on the nurse for many types of physical care and emotional support. A trusting relationship that establishes and maintains an open atmosphere is one that is positive for all involved.