2. Ethics, Ethical Principles & Ethical Decision making frameworks (Mal) PDF

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Ethical Decision Making Frameworks

Lecturer: Mal...

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2. Ethics, Ethical Principles & Ethical Decision making frameworks (Mal) Monday, 6 March 2017

11:41 PM

Intro to Ethics - Ethics is not a black and white subject ○ Always involves thinking and feeling, study and practice, knowledge and intuition ○ Involves the whole person of you, the nurse, and the whole person, of the patient or client ○ Tall order ▪ Also a personal challenge Tschudin, V., & Farr, B. (1994). Nursing ethics VI: Particular features. Nursing Standard, 9(4), 51-57.

What is an ethical issue? Ethics might be experienced as: 1. Ethical violations - clear violations i. Incompetent or deliberate wrong-doing in care 2. Ethical dilemmas - no right or wrong i. Arising from a situation where there may be opposing, but equally morally legitimate approaches to resolve a dilemma; or 3. Ethical distress - e.g. end of life decision making; assisted suicide i. Moral distress (guilt, concern, distaste) arising from action or inaction imposed upon a person by another health professional, organisation or government

Purpose of Ethical Standards - Purpose of the Code of Ethics for Nurses in Australia, (2008) ○ Identify the fundamental ethical standards and values to which the nursing profession is committed, and that are incorporated in other endorsed professional nursing guidelines and standards of conduct ○ Provide nurses with a reference point from which to reflect on the conduct of themselves and others ○ Guide ethical decision making and practice ○ Indicates to the community the human rights standards and ethical values it can expect nurses to uphold

Ethical theories: Consequentialist - Teleological (from the Greek telos: consequences) theories ○ Judge conduct in accordance with its consequences ▪ Utilitarianism is the most famous of these theories ▪ Jeremy Bentham and John Stuart Mill □ Hedonists - their approach to ethics founded upon pursuit of (greatest overall) pleasure - Utilitarianism ○ How do we measure consequences? ▪ Pleasure/pain? (Bentham) ▪ Happiness? (J S Mill) ▪ Ideals? (G E Moore) ○ Whose interests and which consequences are relevant? ▪ Just mine? (egoism) ▪ A group's interests? (group utilitarianism) ▪ Everyone's? (utilitarianism) ○ How do we rank the outcomes?

Lecture Notes Page 1

▪ Dependent upon a ranking of values?

Ethical theories: Deontological theory - Greek: deontos = duty ○ Concerned with the intrinsic rightness or wrongness of an action, not the consequences ▪ Concerned with duty ▪ Ultimate basis: pure reason - Immanuel Kant ○ The only thing in the world which is good without qualification is a good will ○ Kant set out his theory in the 'categorical imperative' ▪ Applies unconditionally □ e.g. 'keep your promises' - Two formulations of the categorical imperative relevant ○ Universal moral law ○ Treat people as ends

Ethical principles - Beauchamp and Childress (2001) ○ Devised four ethical principles to guide ethical reflection within health care - These principles will be used to organise ethical reflection within this unit - These principles and/or sub-principles may be in conflict with each other

Autonomy - The right to choose for yourself what is in your best interest - self-determination ○ 'Every human being of adult years and sound mind has a right to determine what should be done with his own body'

- Two key elements: ○ Capacity for intentional action ○ An absence of restraint or external controlling forces - Creates an ethical obligation for nurses to respect an individual's right to make decisions - J. S. Mill suggests that autonomy should only be limited to protect others from harm Cultural influences on how autonomy is viewed - In some cultures, individual autonomy is not prized over other collective forms of decision making ○ e.g. Indigenous Australians ▪ May be a need for family, community or specific community members to be involved before treatment is considered acceptable □ See P McGrath and E Phillips (2008). Western Notions of Informed Consent and Indigenous Cultures: Australian Findings at the Interface., Journal of Bioethical Inquiry 5(1) pp. 21-31

Beneficence - Duty to benefit and assist others ○ To care for their welfare ○ To always act in the best interests of the patient - To duty extends to the need to undertake professional development and training, to collaborate effectively with others, to keep good records, and to advocate for patients Lecture Notes Page 2

- Carried too far beneficence can become paternalism - Might be given greater priority in circumstances where the autonomy of the individual cannot be established ○ e.g. adults who lack capacity, or children

Non-maleficence - Creates an ethical duty to "do no harm" and to protect others from harm - A health professional must not needlessly harm or injure a patient - There is an ethical duty (reinforced by law) to provide a proper standard of care that avoids or minimises the risk of harm ○ e.g. negligence - This principle affirms the need for professional competence

Justice Distributive utive justice - Distrib ○ The fair distribution and allocation of health services - Rights based justice ○ Respect patient rights - Legal justice ○ Respect morally just laws and be accountable for acts or failures to act (omissions)

Ethical decision making framework

The assessment is structured ACCORDING TO THE FRAMEWORK

Lecture Notes Page 3

1. Identify problem a. Who? i. Hilda - moderate dementia; capacity varies from day to day ii. Nurse with strong European accent - German → need background info about Hilda from e.g. her family, nursing home staff, her GP b. What? i. Refusal to explain ii. Hilda's request seems discriminatory c. Gather info i. Hilda is a survivor of WWII ii. Hilda has PTSD and flashbacks to that time → you CAN'T RESTATE THE SCENARIO SO BE CAREFUL 2. Evaluate a. Ethics i. Code of ethics (4~5 max) 1) VS 2(2) nurses actively preserve the dignity of people 2) VS 3(4) nurses acknowledge the need for non-discriminatory interpersonal relationships 3) VS 4(6) nurses valuing non-harmful, non-discriminatory care 4) VS 6(1) nurses have a moral and legal right to practice in a safe environment ii. Ethical principles - which is the most relevant? Why? (3 principles and outline how they complement/conflict with each other) 1) A - There are limits to autonomy if a person's decisions are likely to harm others a) Hilda's request may harm the nurse by discrimination 2) B and N - attendance of this particular nurse may cause further physical, psychological and emotional distress for Hilda a) Hilda's distress may inadvertently cause physical injury to staff/other patients i) Or emotional distress to staff whose presence may trigger a reaction 3) Justice a) Legal i) As a matter of legal justice to all members of staff the manager should respect the law that prohibits discriminations One. Are there any exceptions to this law? b) Distributive i) Human resources are scarce and there is a question about whether it is fair to other patients to arrange staffing around the request of one patient b. Law i. Legal principles

Lecture Notes Page 4

1) Section 7 of the Anti-Discrimination Act 1991 (QLD) a) It is prohibited to discriminate on the grounds of race. i) Hilda's request relates to the different treatment of staff based on that individual's nationality 2) Section 10(3) a) The motive for discrimination is irrelevant 3) Section 108 a) An exception when a form of discrimination is reasonably necessary to protect the health and safety of people at a place of work i) Is it reasonable and necessary to take action? → conflicts between and within ethical principles and law - There is a conflict between ethical and legal principles □ Beneficence → harmful to the staff member □ Law is clear that it does not matter if the reason for discrimination is beneficent  Unless you could prove that it will affect workplace health and safety 3. Action a. Code of Professional conduct i. CS 4(3) nurses take appropriate action when observing prejudicial and discriminatory attitudes and behaviours ii. CS 3(1) nurses are familiar with relevant laws and ensure they do not engage in clinical or other practices prohibited by such laws 1) Nurses should be familiar with anti-discrimination law iii. CS 8(2) nurse take reasonable measures to establish a sense of trust in people receiving care that their well-being will be protected when receiving care b. Some options of actions i. Refusing Hilda's request 1) May cause serious physical, psychological, and emotional distress/harm to Hilda and to the staff member ii. Agreeing to Hilda's request 1) May constitute direct discrimination against the nurse → action - A decision must be made - The decision must be justified - The nursing manager must take responsibility Some options/examples - Seek urgent expert advice from (potentially): ▪ Geriatrician who specialises in dementia ▪ Lawyer about the act and the impact of other law e.g. occupational safety and health ▪ Other nursing managers, state Department of Health, Commonwealth bodies etc. - Consider talking to relevant staff about the situation 4. Implementation a. A plan must be developed to implement the decision and to address any foreseeable consequences of the decision i. Decision and its rationale must be communicated to Hilda (and her family) ii. Communicate with relevant staff and their union representative iii. Document the decision and its justification iv. Develop a care plan for Hilda v. Run education sessions for staff 5. Evaluation and reflection a. The decision making process should be evaluated b. Seek support when required c. 'Skill up' if necessary

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