1. Ethical Decision Making for the APRN 2015 APRN Spring Conference Tupelo, Mississippi Janie Butts, Ph.D., RN Professor, USM Elizabeth Tinnon, Ph.D., RN, CNE Assistant Professor, USM

2. The ANA DECLARES 2015 AS the “YEAR OF ETHICS”

3. First Nursing Ethics Book Published in 1900 Now, however, not only as individuals, but as a profession, we are beginning to feel an increasing necessity for some such definite moral force or laws that shall bind us more closely together in this bind us more closely together in this work of nursing, and that will bring us into more uniform and harmonious relations. more uniform and harmonious relations. (Elizabeth Hampton Robb, 1900) (Elizabeth Hampton Robb, 1900)

4. Ethics Defined “What should I do?” “How ought I act?’ Various ways of understanding and examining the moral life Various ways of understanding and examining the moral life  Beauchamp & Childress (2012) Is a systematic approach to understanding, analyzing, and distinguishing matters of right and wrong, good and bad, and admirable and deplorable as they relate to human beings, relationships and professional decisions Is a systematic approach to understanding, analyzing, and distinguishing matters of right and wrong, good and bad, and admirable and deplorable as they relate to human beings, relationships and professional decisions  Butts & Rich (2016)

5. What is an Ethical Dilemma A situation where at least two equally justifiable desirable courses of actions OR two equally undesirable courses of action in which a person is uncertain which one to choose A situation where at least two equally justifiable desirable courses of actions OR two equally undesirable courses of action in which a person is uncertain which one to choose A dilemma results in nurses having to analyze the dilemma and come to a resolution for the benefit of the patient, often based on a benefit-risk proportionality A dilemma results in nurses having to analyze the dilemma and come to a resolution for the benefit of the patient, often based on a benefit-risk proportionality A dilemma may require a team effort from the doctor, advanced practice nurse, patients and families, and possibly an ethics committee at the facility A dilemma may require a team effort from the doctor, advanced practice nurse, patients and families, and possibly an ethics committee at the facility ?

6. Confidence & Knowledge: Research Findings Knowledge Knowledge  27 multiple item ethics knowledge exam  Average score 55% Confidence Confidence  Recognize genuine ethical problem  4.26 (Likert 1-5)  Reach sound decision when facing problems  3.86 (Likert 1-5)  Give reasons for your decision  3.83 (Likert 1-5) Laabs, C. (2012) Laabs, C. (2012)

7. Bioethics Definition of Bioethics Every day ethical issues that are raised by real everyday problems of health and illness, which may include medical and nursing ethics, life and death ethics, population ethics, animal ethics, and environmental ethics.

8. Bioethics (cont’d.) Doing Ethics, Doing Bioethics Doing Ethics emphasizes that moral decision-making is an active process. The “doing” is the process by which we analyze issues in order to come to a decision.

9. The Birth of Bioethics 1947 -1987 The horrific treatment of human beings during World War II by Hitler’s Nazi SS in concentration camps and by indoctrinated doctors and nurses conducting experiments “in the name of research” led to the Nuremberg Trials of 1947.

10. The Birth of Bioethics (cont’d.) 1947 -1987 The Nuremberg Code of 1947 to protect humans was created based on the worldwide belief that we would never again allow this inhumane treatment. Later followed: WMA Declaration of Helsinki in 1964 and U. S. Belmont Report in 1978. Today, every organization and university worldwide has a federally- mandated IRB committee to oversee the protection of human subjects.

11. The Birth of Bioethics (cont’d.) 1947 -1987 Childress served on the President’s Council of Bioethics in the 1970s Childress served on the President’s Council of Bioethics in the 1970s Council resulting from rationing of organs and increasing technology Council resulting from rationing of organs and increasing technology First edition of Beauchamp & Childress of Principle's of Biomedical Ethics in 1979 and now in its 7th edition as of 2012 First edition of Beauchamp & Childress of Principle's of Biomedical Ethics in 1979 and now in its 7th edition as of 2012

12. The Birth of Bioethics (cont’d.) 1947 -1987 “Who’s going to pay?” “How do we choose?”

13. Moral Principles Respect for autonomy Respect for autonomy Non-maleficence Non-maleficence Beneficence Beneficence Justice Justice Beauchamp & Childress (1979; 2012)

14. Virtue Ethics Aristotle Two sorts of virtues: Intellect and character Two sorts of virtues: Intellect and character Virtues are developed by character and habitual practice, which is called practical wisdom Virtues are developed by character and habitual practice, which is called practical wisdom Without having practical wisdom one cannot have excellence in character Without having practical wisdom one cannot have excellence in character Known also as character ethics Known also as character ethics A virtuous person will act virtuously. A virtuous person will act virtuously.

15. Virtue Ethics (cont’d.) The concept of virtue is ancient, durable, and pervasive in the whole history of ethical theory. The concept of virtue is ancient, durable, and pervasive in the whole history of ethical theory. The cardinal virtues are: The cardinal virtues are: Wisdom, courage, temperance, justice, generosity, faith, hope, and charity The contemporary virtues are: The contemporary virtues are: Honesty, compassion, caring, responsibility, integrity, discernment, trustworthiness, and prudence.

16. Nursing Ethics The examination of all kinds of ethical and bioethical issues from the perspective of nursing theory and practice, which in turn rest on the agreed core concepts of nursing, namely; person culture/care, health healing, environment and nursing itself. Johnstone (2008, p. 16)

17. Examples of Ethical Dilemmas Privacy and confidentiality Privacy and confidentiality Health care fraud Health care fraud Boundaries and respect Boundaries and respect Social media and behavior Social media and behavior

18. Ethical Decision Making Analysis Models Four Topic Method of Ethical Analysis Four Topic Method of Ethical Analysis by Jonsen, Siegler, Winslade Moral Decision Making Model Moral Decision Making Model by Megan-Jane Johnstone

19. Medical Indications Beneficence & Nonmaleficence Med problem, hx, diag, prog Status, acute, chronic, etc Goals of tx Probability of success What if, therapeutic failure Benefits, and harm avoided Patient Preferences Respect for Autonomy Mentally capable Patient’s preference Risks, benefits, informed consent Incompetent/ surrogate Patient’s preferences prior Is the patient willing Is the patient’s rights being respected Quality of Life Beneficence & Nonmaleficence & Respect for Autonomy Prospects for return to normal Are there any likely deficits r/t Tx Biases present Could life be judged undesirable Plan to forgo treatment Plans for comfort/ palliative care Contextual Features Principles of Loyalty/Fairness Family issues that might affect tx Provider issues that might affect tx Financial and economic factors Religious/ cultural factors Limits on confidentiality Allocation of resources Legal/conflict of interest with parties Four Topics Method of Ethical Analysis by Jonsen, Siegler, Winslade

20. by Megan-Jane Johnstone

21. An Ethical Dilemma Case for You

22. References American Nurses Association. (2015). Code of ethics with interpretive statements. Silver Spring, MD: Author. Beauchamp, T., & Childress, R. (2012). Principles of biomedical ethics (7th ed.). New York: Oxford University Press. Butts, J. B., & Rich, K. L. (2016). Nursing ethics: Across the curriculum and into practice (4 th ed.). Burlington, MA: Jones & Bartlett Learning. Cameron, A. (2011). Impermeable boundaries? Developments in professional and inter-professional practice. Journal of Interprofessional Care, 25, 53-58.

23. References (cont’d.) Chism, L. A. (2016). The doctor of nursing practice (3rd ed.). Burlington, MA: Jones & Bartlett Learning. Fowler, M. D. (2015). Guide to the code of ethics with interpretive statements. Silver Spring, MD: ANA. Grace, P. (2014). Nursing ethics and professional responsibility: In advanced practice (2 nd ed.). Burlington, MA: Jones & Bartlett Learning. Griffith, R. (2013). Professional boundaries in the nurse-patient relationship. British Journal of Nursing, 22(18), 1087-1088.

24. References (cont’d.) Johnstone, M.-J. (2008). Bioethics: A nursing perspective (5th ed.). London Churchill Livingstone. Jonsen, A., Siegler, M. & Winslade, J. (2010). Clinical ethics: A practical approach to ethical decisions in clinical medicine (7th ed.). New York: McGraw-Hill. Laabs, C. (2012). Confidence and knowledge regarding ethics among advanced practice nurses. Nursing Education Perspectives, 33(1), 10-14. Ulrich, C. M., Danis, M., Ratcliffe, S. J. et al. (2006). Ethical conflict in nurse practitioners and physician assistants in managed care. Nursing Research, 55(6), 391-401.