Health Law and Ethics

NRS 2301

Ethical Decision Making

Week 5, Semester 2, 2019-2020

12/14/2021 Ethical Decision Making 1

Ethical Decision Making

Objectives:

By the end of the lecture, the students are expected to:

1. Distinguish between practical problems and ethical dilemmas.

2. Differentiate the moral uncertainty, moral distress and
identify the other moral problems.
3. Examine the process of thoughtful decision making.
4. Describe the role of emotions in ethical decisions.
5. Apply ethical decision making to clinical case scenarios.
Ethical Decision Making
Introduction:
• Each of us makes decisions every day. These decisions are likely routine
and not that difficult to make.

Class Participation Exercise: Give some of examples of the type of

daily decisions you make at home.
Class Participation Exercise: Now give some of examples of the type of
decisions you make in nursing.

 These decisions may be routine patient care management matters, but

they can just as likely be complex matters, such as when to discontinue
feeding a dying patient. These decisions do not come easily and, as
nurses, we may grapple with them.
Ethical Decision Making
Introduction:
 Studies have shown that “30 - 50% of nurses leave bedside patient care
because of moral distress (Burkhardt & Nathaniel 2008, p. 136); the
stress caused by ethical dilemmas.

 This seems like an unnecessary, high figure.

 If nurses are informed about ethics and fully involved in decision making
around moral dilemmas in practice, perhaps more nurses would stay at the
bedside.
Ethical Decision Making
How Do We Know When a Problem is an Ethical One?

 Let’s look at a definition of the word “problem”. It is “a discrepancy

between the current situation and a desired state” (Burkhardt &
Nathaniel 2008, p. 117)

 Problems, of a practical or common nature, are usually:

 Unplanned
 Unexpected
 Personal in nature (self-interest is the primary concern)
 Not morally laden

These problems, such as those volunteered earlier in the

class participation exercise, can be solved once the
relevant information and resources are gathered.
Ethical Decision Making

How Do We Know When a Problem is an Ethical One?

• Ethical or moral problems are different from common problems in that
they usually:
• “Have no easy solution
• Are associated with value laden terms such as, good, bad, harm, benefit, should,
ought to, right, and wrong
• Involve uncertainty and conflict
• “Are not reversible once a decision is made” (Burkhardt & Nathaniel 2008,
p.118)

Moral problem can be defined as a moral matter or issue, that is difficult to

solve or overcome, and requires a “ moral solution”, with varying degrees of
difficulties and complexities, and can lead to moral distress. (Johnstone, 2010)
Problem: A patient in severe and intolerable pain due to not
receiving pain medication.

Practical/Clinical/Technical: the cause of it is neglecting the

patient’s pain, so by the thorough assessment of the patient and
administering the analgesia, we will solve the patient’s problem.

Ethical/ Moral: If the pain was due to the patient’s refusal of pain
relief based on religious grounds, giving the analgesia is not allowed
by the moral demand to respect the patient’s autonomous wishes,
and the nurses’ moral interest in not suffering.

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Ethical Decision Making
The most 10 forms of moral problems are:

1. Moral unpreparedness
2. Moral blindness
3. Moral indifference
4. Amoralism
5. Immoralism
6. Moral complacency
7. Moral fanaticism
8. Moral disagreements and conflicts
9. Moral dilemmas
[Link] stress, or distress
Ethical Decision Making
1. Moral unpreparedness:
 Being unprepared to deal with a moral issue due to moral
incompetency or impairment,lack knowledge or expertise to realize what
is the situation, and not able to deal with its complexities.

 In nursing: this situation , not only can make the nurse inadequate, but
also dangerous, as decisions can be made where there is a lack of
moral competence.
o Example: Moral unpreparedness, resembles clinical unpreparedness.
“A nurse walks into her new unit appointment, turns out to be ICU, and she
receives a patients on a ventilator , that she has never learnt anything
about, or even saw one before!”
Ethical Decision Making

2. Moral blindness :
 A moral blind person, is someone who simply does not
see the moral problem as a problem! Instead he/she see it
as a technical /clinical issue.

Nurses are so conditioned by the clinical context, to the

point that they miss to see a moral problem.

o Example : DNR/ NFR orders*- “RN never thought of it as

moral issue” ,before it was a clinical issue decided by
doctors, and not moral issue decided by ethicists.
Ethical Decision Making
3. Moral indifference;‫ ا;;لالمبا ;اله‬:
o Unconcerned or care-free attitude towards moral issues
or demands
o “Why bother to be moral?”
o Usually such persons do not express any wish or opinion
towards doing, or not doing an action.

Example 1: Applying horn in street!

Example 2 in nursing: A nurse who is not interested in
alleviating patient`s pain despite his complaint, or result of
her assessment ! ( or Not interested in any form of violation of the
patients’ rights).
Ethical Decision Making
4. Immoralism:
oDeliberate violation of accepted or agreed ethical standard
during conduct that is viewed as the right thing to be done, or
morally correct.
oCould be either :
a)Moral turpitude‫ ف;;;ساد‬immorality: (social private duty) anything done on
purpose against what is right and contrary to ethical principles.
b)Moral delinquency wrong behavior: any act that involves negligence of a
moral
duty (carelessness or deliberate violation of agreed standards of
ethical professional conduct).
Class participation:
Give examples on each please? ( racism , sexual or verbal or physical
abuse, theft of pt’s money for personal use , privacy of patients, Falls ).
Ethical Decision Making

5. Amoralism:

 It is a state of ABSENCE of moral concern, and even a rejection of

morality altogether.

 As amoral nurse may reject to have a duty toward patients, or even

reject the idea that patients have rights! (reject to uphold the pt’s
rights, as it doesn’t make sense to talk about the pt’s rights for them).

 A very similar analogue: is the refusal of an atheist to religious terms

(debate the existence of god).
Ethical Decision Making
6. Moral complacency:
 It is a decline to accept that your own moral judgment is
possibly wrong!

Those people just can not accept the fact that they can be
mistaken, and so can not also accept that others can be right
as well.

o Example: A nurse with 30 years of experience in elderly

home, who insists that it is right and proper that all
elderly patients should be uniformly designated to DNR
upon admission to a residential nursing care home , even
without obtaining their permission .
Ethical Decision Making
7. Moral fanaticism‫ا;;لتعصب‬:
 A morally fanatic person is, someone who is absolutely
convinced with certain ideals (believes), following those ideals
without even reflecting , or critically thinking about those
ideals.

In health care setting; a health care professional, might impose

his/ her own moral believes on patients despite their wishes ,
or choice of importance.

o Example: a doctor who insists that being honest to the patients

about their condition is the most important thing, and forces
information on his patients , even if they expressed their wish of not
wanting to know, disregarding by that their autonomy.
Ethical Decision Making
8. Moral disagreements and conflicts :
 It comes in two types:
a) Internal moral disagreement*
 Agreeing on that two moral /ethical principles are important, but to disagree on
what to do when these standards come into conflict and which comes first, or
more important.
 Eg : Two nurses agree and accept the standard of truth telling, ( Nurse A: Favor
telling the truth to patient with cancer, Nurse B: Favor not to tell the truth to patient
with cancer to avoid suffering).
 To agree on moral/ethical standards, but to disagree on what counts as an
accepted exception or limitation for this standard.
 Eg: Both RNs agree to prevent the pt’s rights from being violated, ( Nurse A: act
in situations of violation of pt’s rights even if this threaten her job security, Nurse: B
agree to prevent violation pt’s rights from being violated, but disagree that nurses
should do so even if they lost there job). ---- No Resuolution --- ( Moral Deadlock )
Ethical Decision Making
• Moral disagreements and conflicts (cont’d)
• b) Radical moral disagreement : that could be partial , or complete.

Partial : Agree on some criteria of relevance but not all.

Eg : Nurse A: Disagree on killing a terminally ill patient with a
lethal injection but, agree on letting the patient die naturally.
Nurse B: Disagree on killing a terminally ill patient with a
lethal injection, but disagree on letting the patient die
naturally.
Complete : Don’t agree on any criteria of relevance, and Don’t share any
basic moral principles.
Eg : Nurse A: Reject retrieving organs from patients who are
not fully dead for an organ transplantation as she considers
it as a murder, because its violating the sanctity of life.
Nurse B: Doesn’t consider it as a murder as the sanctity of life
has no substance with the quality of life, (no solution).
Ethical Decision Making

9. Moral dilemmas :
 It is the most discussed type of moral problems in ethics and bioethics.

 It is a situation , where you have to make a choice between two things,

that both are equally undesirable , or both desirable.

 These situation can happen due to: logical incompatibility between 2

different moral principles (ex. P.109), or due to competing moral duties,
and happens also when you have competing or conflict of interests.

 It is also difficult because sometimes the decision is related to people or

certain attachments .
Ethical Decision Making
Moral dilemmas (cont’d)…
• eg : A RN who accepts sanctity of life view and another moral principle as
non- maleficence which demands that persons should be spared
intolerable suffering
• Accepting sanctity of life ----- reject administration of large and potentially
lethal doses of narcotics that might be required to relieve the patient’s
pain
• Following the principle of non-maleficence--- the RN is required to
administer these lethal narcotics.
• ----- in this case the RN is confronted with a dilemma that to uphold the
sanctity of life principle could violate the principle of non-maleficence
• Another Example: Informing patients with cancer about his diagnosis
against family wishes.
Ethical Decision Making
10. Moral distress, stress, and perplexity;‫ ا;;لحيره‬:
 In different literature review done by Johnstone (2010), she defined this
concept as:
“ psychological disequilibrium , and negative feeling state, experienced when a
person makes a moral decision, but does not follow through, by performing the
moral behavior indicated by that decision”.

 Moral distress occurs when one knows the ethically correct action to take but
feels powerless to take that action
 This can happen due to institutional constraints, legal barriers, limited
resources, …etc.

 Perplexity can also lead to distress, as it is a state of moral confusion.

Example: Aggressive patient who requires sedation, but the patient’s
power of attorney, opposes any form of sedation.
Ethical Decision Making

Moral Distress ( cont’d): Moral distress has been shown to

have a major negative impact on
nursing care.

 The consequences of moral distress for nurses:

They avoid patient contact.
They may not give as good patient care.
Their capacity for caring is strained.
They leave the profession.
Ethical Decision Making
Factors that Confound Ethical Problems:
When facing ethical problems, a number of factors contribute to the difficulty of
decision making:

1. Uncertainty : The lack of predictability of the outcome of a certain action.

2. Context : The world in which the patient lives is critical in defining that person,
and influences the selection of one choice over another.

3. Stakeholders : The number of people that might be involved with the decision
and who have strong or competing differences of opinion in what
action to take (patients, family members, close friends , others) .
Ethical Decision Making

Factors that Confound Ethical Problems ( cont’d):

4. Power Imbalance : The difference in influence of the
stakeholders over decisions due to real
or perceived power, and social or
institutional power.
( doctors, nurses , patients )

5. Extraneous Variables : Factors outside the patient care

setting that might influence decision
making, such as laws, previous legal
cases.
eg: believing in euthanasia which is
prohibited in your country.
Ethical Decision Making
Processing an Ethical Dilemma:
 Resolving an ethical problem requires careful deliberation ( diligence ,
vigilance & wisdom) by patients, caregivers, and health
professionals.
 Resolving an ethical problem is best achieved when, actions stay
focused on what is for the best for the patient

The decision-making works best when participants:

 Begin with good will toward each other.
 Are collaborative with each other.
 Adhere to respect and confidentiality.
 Are patient focused.
Ethical Decision Making

Making Ethical Decisions We Can Justify

 Giving good reasons for ethical decisions is called moral
justification.

 Each of the theories and principles discussed in earlier classes

can be used as a starting point in examining a position on an
ethical issue.

 Different points of view among patients, family, and health

professionals can cause disharmony or moral tension in reaching a
solution to a problem.

 Coming to agreement about what is in the best interest of the

patient requires nurses to develop consensus building and good
communication skills.
Ethical Decision Making

Steps to ethical decision making

Ethical Decision Making

 Steps to Ethical Decision Making:

1. Assess the situation:

• Diligent appraisal of facts.

• Operating values in the situation of issue.
Example: assess persons and parties involved, causes, etc…

2. Identify the moral problem you are dealing with:

Example: is it related to religion, culture, race, etc…..
Ethical Decision Making

Steps to Ethical Decision Making:

3. Set moral goals and plans:
• Appropriate course of actions.
• Explore all moral alternatives that can address the situation.
• Weight between different alternatives.

4. Implement the plan of moral care:

5. Evaluate moral outcomes : if the desired moral

outcome, has not been achieved, you may need to re-do the whole
process.
Ethical Decision Making
Steps to Ethical Decision Making:

Important questions to ask during the steps of ethical

decision making might include:
• What is the issue here?
• Are there are hidden issues?
• Where are the conflicts?
• What are the ethical theories/principles that apply?
• What are reasonable alternatives to resolve the problem?
• How do the alternatives rest with my
personal/professional values?
• Are you treating others as you would want to be treated?
• How do the key parties want to resolve the problem?
• Would you be comfortable if your decision making were
publicized?
Ethical Decision Making

Emotions in Decision Making:

I

You may have noticed that the ethical decision making approach is
largely based on reasoning.

We know, however, that moral dilemmas are emotionally charged

situations.

Callahan (2000) says it is important that emotions play a role in informing

our ethical decision making. Emotions provide information on how we
feel about what is right or wrong in a situation.
Example: inserting IV Cannula for a sick child.

We ought to pay attention to feelings especially when, cognitively, we

might be directed to act in a certain way, but our emotional responses to
taking that action cause great discomfort or tension.
Ethical Decision Making

Emotions in Decision Making:

Callahan warns of the seriousness in devaluing

feelings in moral dilemmas:
“numbness, apathy, isolated disassociations between thinking and
feeling are moral warning signs” we must guard against (as cited in
Burkhadt & Nathaniel 2008, p. 127).

 The goal is to have “head and heart in harmony as an ethical

decision is made.” (Burkhadt & Nathaniel 2008, p. 127).

 Sound decision - making requires a collaboration between reason

and emotion
Ethical Decision Making

Summary
 An ethical dilemma occurs when there appears to be no satisfactory
easy solution to a problem and there are conflicts between ethical
principles, values, duties, and rights.

 Ethical problems may cause strong emotional feelings or “moral

distress”.

 Moral distress may have significant negatives consequences for patient

care.

 Ethical decision making is a reflective process using both reasoning and

emotions.
Ethical Decision Making
Summary
 Ethical decision making involves defining the problem, identifying
a desired goal, gathering information, comparing options, choosing
the best course of action and evaluating the outcomes of the choice.

 Identification of one’s own value system as well as the value system of

the key stakeholders involved in the ethical situation are critical to how
an ethical dilemma resolved.

- Life experience plays a very major role in dealing with moral issues and moral
distress.

 Nurses who practise applying the concepts of ethics and the steps of a
decision making model in the realities of day-to-day practice will develop the
competence and confidence with ethical decision making.
References:

Burkhardt, M. & Nathaniel, A. (2014). Ethics and issues in

contemporary nursing. 4th Edition. Canada: Delmar Cengage
Learning.
Johnstone, M. (2016). Bioethics: a nursing perspective. 6th Edition.
Australia: Churchill Livingstone.