Melody Brown Hellsten, DNP, RN, PPCNP-BC, CHPPN INTRIGUING ETHICAL CHALLENGES IN PEDIATRIC ONCOLOGY NURSING

ETHICS – A BIT OF HISTORY AND SOME DEFINITIONS Ethical philosophy –Aristotle – Aristotle – ‘what is the good life for man? – Soul as three things – passions, faculties and states of character (virtue) – Distinguished between moral and intellectual virtues Morals – Right/wrong, good/bad, what is/is not acceptable behavior – Define a person’s character Morals vs Ethics – Morals define a person’s character – Application of morals (personal character) in a social context

ETHICAL THEORIES (ANA Ethical Relativism – Morality is relative to the culture in which you live – No absolute truth, context is important – Right/Wrong varies from person to person, culture to culture Deontology – Morality as an action’s adherence to rules – Does not evaluate consequences, examines essential moral worth of intention of act Utilitarianism – What is best for most people – Value of act is determined by usefulness, emphasis on outcome/consequences

NURSING ETHICS (FOWLER MD. HERITAGE ETHICS: TOWARD A THICKER ACCOUNT OF NURSING ETHICS. (2015) NURSING ETHICS DOI / Nightingale – first ethical duty was to the patient Confidentiality was earliest ethical norm in nursing – Mentioned in the Nightingale pledge – Predates field of bioethics Early nursing ethics in US – Virtue ethic – Character as key element of ethical behavior First example of research in nursing ethics – 1935 Sr Rose Helene Vaughn – The actual incidence of moral problems in nursing: a preliminary study in empirical ethics – Abstracted 2265 ethical incidence, 33 categories Primary clinical-moral problem was cooperation between physicians and nurses

ANA CODE OF ETHICS FOR NURSES WITH INTERPRETIVE STATEMENTS Most recent version principles – compassion and respect for inherent dignity, worth and unique attributes of every person – Primary commitment is to patient – Promotes, advocates for and protects rights, health and safety of patients – Authority and accountability and responsibility for nursing practice – Owes same duties to self as to others – Establish, maintain and improve ethical environment of work setting – Advances profession through research and scholarly inquiry, professional standards, and nursing/health policy – Collaborates with other health professionals and public to protect human rights, promote health diplomacy and reduce health disparity – Articulate nursing values, maintain integrity of profession, integrate principles of social justice into nursing and health policy

NURSING AND VIRTUE ETHICS Steady, unchangeable character internal to one’s identity – Virtues: caring, compassion, honesty, faithfulness, kindness, patience, justice, temperance, courageous, and tolerance. – Vices: cruel, unkind, dishonest, impatient, unjust, untruthful…. Gives directions for action – Presents an account of right action

NURSING AND BIOETHICS Justice: – The duty to treat all fairly, distributing the risks and benefits equally. Autonomy: – the duty to maximize the individual's right to make his or her own decisions. Veracity: – the duty to tell the truth. Veracity: – the duty to tell the truth. Understanding/Tolerance: – The duty to understand and to accept other viewpoints if reason dictates doing so is warranted Equality: – the duty to view all people as moral equals.

NURSING ETHICS Virtue Ethics? Bioethics? Both?

ETHICAL DILEMMAS IN NURSING Nurse-Person Nurse-Nurse Nurse-Physician Nurse – Institution

Identify the ethical challenge – Ongoing treatment of refractory cancer with increasing suffering gather the facts consider values/beliefs of individuals involved look for consensus/balance develop options based on particular circumstance. ETHICAL DECISION MAKING

Medical Indications Patient Preferences Quality of Life FOUR BOX METHOD Contextual Factors Jonsen, Siegler, and Winslade (2006)

 Best Interest Standard  When, How applied?  Who determines the child’s best interest  Parent  Health Care Team  Ethics Committee  Judges  Better frameworks?  Harm Standard  Phronetics ETHICAL DECISION MAKING

Substituted Judgment – Occurs when others decide for a patient that is not competent – Children are not legally competent to make medical decisions – Role of child in determining preferences for medical care Raises issues in verbal children and adolescents Assent Professional, Parent, Child conflict ETHICAL DECISION MAKING

 Involving Children in Medical Decision Making ◦ Developmental Considerations ◦ Family Considerations ◦ Provider Considerations ETHICAL DECISION MAKING

CASES AND CONVERSATION