1. Chapter 22 Ethics and Values
Ethics is the study of conduct and character. It is concerned with determining what is good or valuable for individuals, groups, and society at large.
Acts that are ethical reflect a commitment to standards that individuals, professions, and societies strive to meet. When decisions must be made about health care, understandable disagreement can occur among health care providers, families, patients, friends, and people in the community. The right thing to do can be hard to determine when ethics, values, and perceptions about health care collide.
This chapter describes concepts that will help you embrace the role of ethics in your professional life and promote resolution when an ethical dilemma develops.
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2. Basic Terms in Health Ethics
Autonomy
Commitment to include patients
in decisions
Beneficence
Taking positive actions to help others
Nonmaleficence
Avoidance of harm or hurt
Justice
Being fair
Fidelity
Agreement to keep promises
Standards of ethics in health care include autonomy, beneficence, nonmaleficence, justice, and fidelity.
Respect for patient autonomy refers to the commitment to include patients in decisions about all aspects of care as a way of acknowledging and protecting a patient’s independence. Involving patients in decisions about their care is now standard practice. Providers are obligated to inform patients about risks and benefits of treatment plans and then to ensure that they understand and agree with their plan.
Respect for provider autonomy refers to provider relationships to institutions.
The principle of beneficence is fundamental to the practice of nursing and medicine. The agreement to act with beneficence implies that the best interests of the patient remain more important than self-interest.
Maleficence refers to harm or hurt; thus nonmaleficence is the avoidance of harm or hurt. In health care, ethical practice involves not only the will to do good, but an equal commitment to do no harm.
Justice refers to fairness. It is used most often in discussions about access to health care resources, including the just distribution of resources. The term just culture refers to the promotion of open discussion without fear of recrimination whenever mistakes, especially those involving adverse events, occur or nearly occur.
As a nurse, you keep promises by following through on your actions and interventions. Fidelity also refers to the unwillingness to abandon patients regardless of the circumstances, even when personal beliefs differ as they may when dealing with drug dealers, members of the gay community, women who received an abortion, or prisoners.
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3. Professional Nursing Code of Ethics
Code of nursing ethics
A set of guiding principles that all members of a profession accept
Helps professional groups settle questions about practice or behavior
Includes advocacy, responsibility, accountability, and confidentiality
Social networking
Presents ethical challenges for nurses
The American Nurses Association (ANA) code of ethics provides a foundation for professional nursing.
A code of ethics can be defined as a collective statement about the group’s expectations and standards of behavior.
The ANA established the first code of nursing ethics decades ago.
The ANA reviews and revises the code regularly to reflect changes in practice. However, basic principles of responsibility, accountability, advocacy, and confidentiality remain constant.
Advocacy refers to the support of a particular cause. As a nurse you advocate for the health, safety, and rights of patients, including their right to privacy and their right to refuse treatment.
Responsibility refers to willingness to respect obligations and to follow through on promises.
Accountability refers to the ability to answer for one’s own actions. Standards are set by The Joint Commission and the ANA. Health care facilities have compliance officers who are responsible for making sure that the institution remains in compliance with standards and regulations.
The concept of confidentiality is well established. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates protection of the patient’s personal health information.
Social networks can be a supportive source of information about patient care or professional nursing activities. The risk to patient privacy is great. Posting a photo with no identifiers should not be practiced, as sometimes, the patient can still be identified. Becoming friends with patients may cloud your ability to remain objective. Workplace policies will guide your decisions in engaging with social media.
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4. Principles of ANA Code of Ethics
Advocacy
Support of a particular cause. Ex: As a nurse, you advocate for clients’ health, safety, rights, including privacy
Responsibility
Refers to a willingness to respect one’s professional obligation and follow through on promises. Nurses are responsible for their actions and actions of those to whom you delegate
Accountability
Refers to ability to answer for one’s own actions.
Confidentiality
HIPPA mandates the protection of patient’s personal health information.
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5. Case Study
Anna Moreno is an 82-year-old African-American widow and retired schoolteacher. She lives with her 55-year- old daughter and three teenage grandchildren. Her daughter, Lucille, is a single mother and a full-time nurse.
Anna assists with the care of her grandchildren when her daughter is at work. She also volunteers at the library and at her church. She has diabetes and high blood pressure, both controlled with diet and medication.
[This case study will be presented in several sections throughout this presentation. Encourage discussion with nursing students of each section of the case study. After the entire case study has been presented, the slide presentation will include a summary of the case study as it relates to nursing philosophies and perspectives on ethics and values.]
[Ask students: What have we learned so far? Who in this case study is likely to need further health care in the near future? Discuss.]
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6. Quick Quiz!
1. Your patient is about to undergo a controversial orthopedic procedure. The procedure may cause periods of pain. Although nurses agree to do no harm, this procedure may be the patient’s only treatment choice. Which ethical principle does this situation describes?
A. Autonomy.
B. Fidelity.
C. Justice.
D. Nonmaleficence.
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7. Values Value Values clarification
A value is a personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior.
Values clarification
Ethical dilemmas almost always occur in the presence of conflicting values.
To resolve ethical dilemmas, one needs to distinguish among values, facts, and opinion.
Nursing practice requires you to be in contact with patients physically, emotionally, psychologically, and spiritually.
In most other intimate relationships, you choose to enter the relationship precisely because you anticipate that your values will be shared with the other person.
But as a nurse, you agree to provide care to your patients solely on the basis of their need for your services.
As a nurse, you will need to respect your own values even as you try to respect those of others whose values differ from yours.
To negotiate differences of value, it is important to be clear about your own values: what you value, why, and how you respect your own values even as you try to respect those of others whose values differ from yours.
The values that an individual holds reflect cultural and social influences, and these values vary among people and develop over time.
Sometimes people have such strong values that they consider them to be facts, not just opinion. Sometimes people are so passionate about their values that they become judgmental in a way that intensifies conflict. Clarifying values—your own, your patients’, your co-workers’—is an important and effective part of ethical discourse. In the process of values clarification, you learn to tolerate differences in a way that often (although not always) becomes the key to the resolution of ethical dilemmas.
Identifying values as something separate from facts can help you find tolerance for others, even when differences among you seem worlds apart.
[Review Box 22-1, Cultural Values Exercise, with students.]
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8. Ethics and Philosophy Deontology Utilitarianism Feminist Ethics
Defines actions as right or wrong
Utilitarianism
Proposes that the value of something is determined by its usefulness
Feminist Ethics
Focuses on the inequality between people
Ethics of Care
Emphasizes the importance of understanding relationships, especially as they are revealed in personal narratives
Casuistry
Case-based reasoning
Historically, health care ethics constituted a search for fixed standards that would determine right action. Ethics has grown into a complex field of study, more flexible than fixed, filled with differences of opinion and deeply meaningful efforts to understand human interaction.
These philosophies, or theories on ethics, provide a foundation for developing strategies to use when an ethical dilemma occurs:
Deontology: proposes a system of ethics that is perhaps most familiar to health care practitioners. Deontology defines actions as right or wrong based on their “right-making characteristics,” such as fidelity to promises, truthfulness, and justice. Deontology depends on a mutual understanding of justice, autonomy, and goodness. But it still leaves room for confusion to surface.
Utilitarianism: A utilitarian system of ethics proposes that the value of something is determined by its usefulness. This philosophy is also known as consequentialism because its main emphasis is on the outcome or consequence of an action. A third term associated with this philosophy is teleology, from the Greek word telos, meaning “end,” or the study of ends or final causes. The greatest good for the greatest number of people is the guiding principle for determining right action in this system.
Feminist Ethics: Feminist ethics critiques conventional ethics such as deontology and utilitarianism. It looks to the nature of relationships to guide participants in making difficult decisions, especially relationships in which power is unequal, or in which a point of view has become ignored or invisible. Writers with a feminist perspective tend to concentrate more on practical solutions than on theory. Feminist ethicists propose that the natural human urge to be influenced by relationships is a positive value.
Ethics of Care: The ethics of care and feminist ethics are closely related. Both promote a philosophy that focuses on understanding relationships, especially personal narratives. An early proponent of the ethics of care used the term the one-caring to identify the individual who provides care, and the cared-for to refer to the patient or patients. In adopting this language, the author hoped to emphasize the role of feelings.
Casuistry, or case-based reasoning, turns away from conventional principles of ethics as a way to determine best actions and focuses instead on an “intimate understanding of particular situations.” This approach to ethical discourse depends on finding consensus more than an appeal to philosophical principle. As a strategy for solving dilemmas, consensus building promotes respect and agreement rather than a particular philosophy or moral system itself.
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9. Case Study (Cont.)
Lucille accompanies her mother to the physician’s office for a routine visit. When her mother steps out to have some lab work done, Lucille asks to speak privately to the nurse, Mary Ann, and reveals some serious concerns.
Lucille had received a call from the manager of the library where her mother volunteers. The manager described finding Ms. Moreno in the janitor's closet one day, confused and tearful. 
[Ask students: What is your initial reaction to this situation? Discuss.]
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10. Case Study (Cont.)
The manager expressed growing concern about Ms. Moreno’s ability to finish tasks, such as reshelving books and taking phone messages. She recommended that Lucille get an evaluation of her mother’s mental status.
Lucille tells the nurse that she is not at all convinced that her mother is having mental problems. 
[Ask students: Why do you think Lucille is convinced that her mother is not having mental problems? Who do you think is in the best position to know whether Ms. Moreno is having problems with her mental health? Discuss.]
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11. Nursing Point of View
Nurses generally engage with patients over longer periods of time than other disciplines.
Patients may feel more comfortable revealing information to nurses.
All patients in health care systems interact with nurses at some point, and they interact in ways that are unique to nursing.
They are involved in intimate physical acts such as bathing, feeding, and special procedures. As a result, patients and families may feel more comfortable in revealing information not always shared with physicians or other health care providers.
Your ability to shape your care on the basis of this special knowledge provides an indispensable contribution to the overall care of your patient.
The care of any patient involves the collaboration of many disciplines. Managers and administrators from many different professional backgrounds contribute to ethical discourse with their knowledge of systems, distribution of resources, financial possibilities and limitations.
[Shown is Figure 22-1: Nurses collaborate with other professionals in making ethical decisions.]
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12. Processing an Ethical Dilemma
Step 1: Ask if this is an ethical dilemma.
Step 2: Gather all relevant information.
Step 3: Clarify values.
Step 4: Verbalize the problem.
Step 5: Identify possible courses of action.
Step 6: Negotiate the outcome.
Step 7: Evaluate the action.
Ethical dilemmas cause distress for patients and caregivers.
Resolving an ethical dilemma is similar to the nursing process in its methodical approach to a clinical issue. It differs in that it requires negotiation of differences of opinion and clarity about situations that are confusing and not easily solved by appealing to the usual ethical principles.
A process for resolving ethical dilemmas that respects differences of opinion and all participants equally helps health care providers resolve conflict about right actions.
These seven steps will guide you through assessment, planning, implementation, and evaluation of an ethical dilemma.
[Review Box 22-2, Key Steps in the Resolution of an Ethical Dilemma, with students.]
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13. Institutional Resources
Ethics committees are usually multidisciplinary and serve several purposes: education, policy recommendation, and case consultation.
Any person involved in an ethical dilemma, including nurses, physicians, health care providers, patients, and family members, can request access to an ethics committee.
Health care institutions establish ethics committees to process ethical dilemmas.
Nurses provide insight about ethical problems at family conferences, at staff meetings, and even in one-on-one meetings.
Many ethical problems begin when people feel misled or are not aware of their options and do not know when to speak up about their concerns.
Ethics committees serve to complement relationships within the workplace and the community and offer a valuable resource for strengthening these relationships.
A process for resolving ethical dilemmas that respects differences of opinion and all participants equally helps health care providers resolve conflict about right actions.
[Review Box 22-3, Evidence-Based Practice: Moral Distress, with students.]
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14. Issues in Health Care Ethics
Quality of life: Central to discussions about end-of-life care, cancer therapy, physician-assisted suicide, and Do Not Resuscitate (DNR)
Disabilities: Antidiscrimination laws enhance the economic security of people with physical, mental, or
emotional challenges
Care at the end of life: Interventions unlikely to produce benefit for the patient
Health Care Reform: Facilitated access to care for millions of uninsured Americans
Ethical issues change as society and technologies change, but common denominators remain: the basic process used to address the issues and your responsibility to deal with them.
These professional ethical/bioethical issues will influence you and the care you give your patients: quality of life, genetic screening, and care at the end of life.
Quality-of-life measures may take into account the age of a patient, the patient’s ability to live independently, his or her ability to contribute to society in a gainful way, and other nuanced measures of quality. Still a definition remains deeply individual and difficult to predict.
The question of quality of life is central to discussions about quality of care, outcome measures, care at the end of life, futile care, cancer therapy, and health care provider–assisted suicide.
The national movement to respect the abilities of all, regardless of their functional status, has inspired a reconsideration of the definition of quality of life. Antidiscrimination laws enhance the economic security of people with physical, mental, or emotional challenges.
The capabilities approach “begins with a commitment to the equal dignity of all people, whatever their class, religion, caste, race, or gender, and it is committed to the attainment, for all, of lives that are worthy of that equal dignity.”
Difficult emotional and spiritual challenges resulting in moral distress can characterize the management of care at the end of life. The term futile refers to something that is hopeless or serves no useful purpose. In health care discussions, the term refers to interventions unlikely to produce benefit for a patient.
If a patient is dying of a condition with little or no hope of recovery, almost any intervention beyond symptom management and comfort measures is seen as futile. In this situation, an agreement to label an intervention as futile can help providers, families, and patients turn to palliative care measures as a more constructive approach to the situation.
The legislation also incorporates a promotion of wellness by proposing changes in payment for services and by rewarding practices that reduce harm and promote quality outcomes.
[Review Box 22-4, Cultural Aspects of Care: Access to Affordable Health Care, with students.]
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15. Ethics and Access to Care
The number of uninsured in the united states grew from 39 million people in 2000 to more than million people by 2008—more than 15% of the total population.
Many of the uninsured are women and children.
Although two thirds of the uninsured are poor, nearly 80% come from working families.

16. Ethical Issues on Aging
Older people usually are not as familiar with the concept of autonomy as are people from younger generations.
As people age, they develop clinical conditions that affect the communication process. Some patients become incapacitated by stroke or disease. Most older adults take multiple medications, some of which affect cognitive skills in subtle ways.
Consensus about medical goals for the older adult is hard to achieve.
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17. Quick Quiz!
2. If a nurse decides to withhold a medication because it might further lower the patient’s blood pressure, which principle will the nurse will be practicing? A. Responsibility. B. Accountability. C. Competency. D. Moral behavior.
Answer: B
Rationale: If a nurse decides to withhold medication, despite a provider’s order, the nurse is then accountable for his or her actions, as the nurse made the independent decision because of his or her knowledge of the patient and the patient’s situation at that moment in time.
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18. Case Study (Cont.)
From Mary Ann’s perspective, Lucille seems angry and defensive about the manager’s report. She even accuses the manager of discrimination against older adults. She adamantly refuses offers of a physical or mental evaluation for her mother, or even to discuss the issues with her mother. Instead, she requests that the nurse write a letter that validates her mother’s good health.
What do you think about Lucille’s reaction?
Do you agree with Mary ANN?
What do you think Mary ANN will do?
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19. Case Study (Cont.)
After all, Lucille argues, her mother’s blood pressure is normal, and her blood glucose levels are within normal limits.
Mary Ann realizes that this situation is complex. She will need to get the help of others to sort out the best response to Lucille’s request.
Is this an ethical dilemma for Mary Ann?
Let’s consider the situation that this case presents to the nurse, Mary Ann, in terms of how to process an ethical dilemma.
[Review the steps for processing an ethical dilemma. You might choose to review them now with students, then return to examine them individually as they relate to this case study, in the following slides. Step 1 is discussed here, Steps 2 and 3 on the next slide, and Steps 4 through 7 and the conclusion on the following slide.]
Step 1: Is this an ethical dilemma?
If a review of scientific data does not resolve the question, if the question is perplexing, and if the answer will have profound relevance for several areas of human concern, then an ethical dilemma exists.
In this case study, Mary Ann is perplexed by her options. She cannot write a letter about Ms. Moreno’s state of health without knowing more, but Ms. Moreno’s daughter refuses to seek more information.
For Mary Ann, an ethical dilemma exists.
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20. Case Study (Cont.)
Mary Anne has determined that the situation is an ethical dilemma. Now she must:
Step 2: Gather all information relevant to the case.
Step 3: Examine and determine her own values and opinions about the issues.
We have seen in Step 1 that Mary Ann has concluded that an ethical dilemma exists. Let’s continue to apply the steps of this process now.
Step 2: Gather all information relevant to the case.
Complete assessment of the facts of the case is critical to an effective decision. An overlooked fact sometimes provides quick resolution, or deeply affects the options available.
Patient, family, institutional, and social perspectives are important sources of relevant information.
In the case of Ms. Moreno, the medical record would provide important information. Other sources might include psychosocial information about Ms. Moreno’s daughter and her children.
Step 3: Examine and determine your own values and opinions about the issues.
Values clarification provides a foundation for clarity and confidence during discussions that are necessary for resolution of a dilemma. Taking this step ensures that you are able to distinguish between your personal values and those of the other participants and allows you to become a more open listener.
If you were the clinic nurse in the case study, how would you feel about elder care, child care, working mothers?
[Steps 4 through 7 are covered on the following slide.]
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21. Case Study (Cont.) Step 4: State the problem clearly.
Step 5: Consider possible courses of action.
Step 6: Negotiate the outcome.
Step 7: Evaluate the action.
Step 4: State the problem clearly.
A clear, simple statement of the dilemma is not always easy, but it is essential for the next step to take place.
The immediate dilemma involves the request to validate Ms. Moreno’s competence without enough information to make an honest assessment.
Step 5: Consider possible courses of action.
To respect all sides of an issue, it is helpful to list potential actions, especially when the list will reflect opinions that conflict.
Actions might include consulting with a social worker and a gerontologist.
Eventually, the course of action will likely involve decisions about Anna Moreno’s ability to continue her work at the library.
Step 6: Negotiate the outcome.
Sometimes courses of action that seem unlikely at the beginning of the process take on new possibility as they are put to rational and respectful consideration.
Negotiation requires confidence in your own point of view and a deep respect for the opinions of others.
For Anna Moreno and her family, effective negotiation with Anna’s daughter is critical to a positive outcome.
Step 7: Evaluate the action.
The last step in resolving an ethical dilemma involves evaluating the outcomes. Do the interventions provide for a compromise that is acceptable to all? Have the actions taken helped to answer the questions that you identified at the beginning of the process?
An ethical dilemma is often emotionally complicated, so it will be helpful to review the original issues to ensure that the process has worked.
For Anna Moreno, even though the dilemma arose around the request for a letter, other issues were identified and addressed during the process: Ms. Moreno’s possible mental decline, child care issues for Ms. Moreno’s grandchildren, and the fact that her daughter Lucille was refusing outside help.
Mary Ann gathers all the facts and includes others in the process. She collaborates with a social worker and a gerontologist. Together, the three professionals meet with Lucille. When they present their concerns to Lucille in a clear, professional manner, Lucille is able to look at the situation realistically, rather than letting her emotions and fears get in the way. Lucille realizes that her mother does need to undergo testing.
Mary Ann helps Lucille to make the appointments and arrangements for all of the tests that Lucille’s mother needs. Lucille realizes that just pretending that nothing is wrong, or being angry about the situation, is not a solution. The resolution to the ethical dilemma in this case study presented is effective and satisfying. [Discuss.]
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22. Who is most likely to encounter an ethical dilemma?
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23. Question
Which of the following provides a foundation for professional nursing?
A. American Nursing Association Code of Ethics.
B. The institutional Ethics Committee.
C. The nurse’s values clarification.
D. The hospital’s policy and procedure manual.
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24. Group Activity
Defined and provide an example of each principles of the ANA Code of Ethics: Accountability, Responsibility, Advocacy, and Confidentiality
Describe each of the following philosophies and provide an example each: Deontology, Utilitarianism, Feminist Ethics, Ethics of Care, and Cauistry.
Describe and provide an example of autonomy, beneficence, nonmaleficence, justice, and fidelity.
Provide examples of how culture can cause an ethical dilemma.
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