ETHICAL PRINCIPLES

-are basic and obvious moral truths that guide deliberation and action RESPECT FOR PERSONS -implies that one considers others to be worthy of high regard. Certainly, genuine regard and respect for others serves as the cornerstone of any caring profession. There are following ethical principles: Autonomy, beneficence, nonmaleficience, veracity, confidentiality, justice, and fidelity.

PRINCIPLE OF AUTONOMY:
Literally means self governing. It is frequently used, yet poorly understood. Aveyard (2000)-denotes autonomy as having the freedom to make uses about issues that affect ones life. Is closely linked to the notion of respect for persons. An important principle in cultures where all individuals are considered to be unique and valuable members of the society. Implies that each person has the freedom to make decisions about personal goals. It is a state in which each of us is free to choose and implement our own decisions, free from lies, restraint or coercion. FOUR BASIC ELEMENTS of an autonomous person: 1. Autonomous person is respected. It is logical that those choosing the nursing the nursing profession would inherently value and respect the unique humanness of others. This element is essential to assuring autonomy. 2. Autonomous person must be able to determine personal goals. These goals maybe explicit and of a global nature, or maybe less well defined. 3. Autonomous person has the capacity to decide on a plan of action. The person must be able to understand the meaning of the choice to be made and deliberate on the various options, while understanding the implications of the possible outcomes. 4. Autonomous person has the freedom to act upon choices. In situations were persons are capable of formulating goals, understanding various options, and making decisions, yet are not free to implement their plans, autonomy is either limited or absent. Autonomy maybe limited in situations where the means to accomplish autonomously devised plans do not exists.

A number of intrinsic factors may threaten the patient autonomy. The patients role is a dependent one. The patient seeks health care assistance because of the real or perceived need and, as a result, can be thought of as being dependent upon the health care provider. The role of a health care professional on the other hand, is one of power. This power is based upon knowledge and authority and is inherent in the role. The complementary relationship, while a necessary one, can lead to violations of patient autonomy. RECOGNIZING VIOLATIONS OF PATIENT AUTONOMY Often, nurses and other health care workers fail to recognize subtle violations of patient autonomy. This especially occurs when nurses perceive choices to be selfevident. A least four factors are related to this failure. 1. Nurses may falsely assume that patients have the same values and goals as themselves. This state of mind compels some nurses to believe that the only reasonable course of action is the one that is consistent with their own values. This leads to faulty conclusion. Example: If an elderly person chooses to stay in her own home, eventhough to others she seems to be incapable of caring for herself, the choice might be viewed as unreasonable and might become grounds to believe the patient is incompetent to make decisions. In truth, the elderly person may recognize that life is drawing to a close and might want to remain in familiar surroundings, maintain dignity, remain dependent and prevent needless depletion of her life savings. 2. Lies in our failure to recognize that individuals thought processes are different. Discounting a particular decision as incorrect may not take into consideration the fact that people process information in different ways. Example: There are those whose thought processes are very logical and methodical; others think in ways that are creative and free- flowing. It is important to recognize these types of differences when several people are working together to come up to a common decision. 3. Lies in our assumptions about patients knowledge base. It is easy for us to forget that we have gained a specialized body of knowledge through our programs of basic nursing education and extensive work experience that is easy to presume everyone has at least some of the same type of knowledge. Consequently, we may discount or criticize patients decisions; eventhough flaws lie in the patients level of knowledge, rather than the appropriateness of decisions.

4. Lies in the unfortunate fact that in some instances the work of nursing becomes the major focus. This produces a climate of industrious habit. As we go about our work-doing procedures, giving medications, writing care plans and trying to keep up a frantic pace-attentiveness to assuring patients autonomy is sometimes neglected. INFORMED CONSENT -Relates to a process by which patients are informed of the possible outcomes, alternatives, and risk of treatments and are required to give their consent freely. It assures the legal protection of a patients right to personal autonomy in regards to specific treatment and procedures. The concept of informed consent is one that has come to mean the patients are given the opportunity to autonomously choose a course of action in regard to plans for medical care. Paternalism/Parentalism Is a gender biased term that literally means acting in a fatherly manner. Paternalism is appropriate when a patient is judged to be incompetent or to have diminished decision making capacity. Noncompliance Is generally thought of as denoting an unwillingness of the patient to participate in health activities. Example: Taking medications as scheduled, maintaining a therapeutic or weight loss diet, exercising regularly and quitting smoking. Use of the term is just as likely to represent failure of the nurse as that of the patient.

PRINCIPLE OF BENEFICENCE
-is one that requires nurses to act in ways that benefit patients. The objective of the beneficence provides nursing context and justification. It lays the groundwork for the trust that society places in the nursing profession, and the trust that individuals place in particular nurses or health care agencies.

Beauchamp and Walters,1999- There is no controversy as to whether nurses are obligated to act beneficently- beneficent acts are morally and legally demanded by our professional role. The ethical principle of beneficence has 3 major components: 1. We ought to do or promote good. It seems safe to assume that the intention of nurses is to promote good. Questions arise when, in particular situations, those involve cannot decide what is good. Example: Consider the case of a patient who is in the process of lingering, painful, terminal illness. There are those who believe that life is sacred and should be preserve at all costs. Others believe that death is preferable to a life of pain and dependence. The definition of good in any particular case will determine, at least in part, the action that is to be taken. 2. We ought to prevent evil or harm. Some believe that doing no harm and preventing or removing harm,is more Imperative than doing good. All codes of nursing ethics requires us to prevent or remove harm. Example: The nurse takes appropriate action to safeguard individuals when their care is endangered by a co-worker or any other person. 3. We ought to remove evil or harm. Steps includes the following: expressing concern to the person carrying out the questionable practice, reporting the practice to the appropriate authority within the institution, and if not corrected reporting the problem to other appropriate authorities like professional organizations or licensing boards.

PRINCIPLE OF NONMALEFICENCE
-Is related to beneficence. This principle requires us to act in such a manner as to avoid causing harm to patients. Included in this principle are deliberate harm, risk of harm, and harm that occurs during the performance of beneficial acts. Hippocratic tradition says: first do no harm-principle of nonmaleficience, which places this principle among others. Nonmaleficience also means avoiding harm as a consequence of doing good. In such cases, the harm must be weighed against expected benefit.

Example: Sticking a child with a needle for the purpose of causing pain is always bad-there is no benefit. Giving an immunization, on the other, while causing similar pain, results in the benefit of protecting the child from serious disease. The harm caused by pain of the injection is easily outweighed by the benefit of the vaccine. In a day to day practice, we encounter many situations in which the distinction is less clear, either because the harm caused may appear to be equal to the benefit gained, because the outcome of a particular therapy cannot be assured, or as a result of conflicting beliefs and values. Example: Consider analgesia for patients with painful terminal illness . Narcotic analgesia maybe the only type of medication that will relieve very severe pain. This medication however, may result in dependence and can hasten death when given in amounts required to relieve pain.

PRINCIPLE OF VERACITY
Relates to the practice of telling the truth. Truthfulness is widely accepted as a universal virtue. Martin Buber (1965), suggest that the true communication between people can take place only when there are no barriers between them. Lying or deception creates a barrier between people and prohibits both meaningful communication and the building of relationships. Violating the principle of veracity shows lack of respect. Telling lies, or avoiding disclosure, implies that the specific function of the nurse or other person involved assumes prominence over the patient ,or at the very least, the autonomy of the patient. Joseph Ellin (1991) discusses special considerations that have been posed by the medical profession in relation to truth telling. He suggest that it does not seem beneficent to adopt an ethic of absolute veracity in which it is obligated to cause avoidable anguish to someone who is already ill, especially when hope and positive outlook may promote healing and help prolonged life. He writes one could hope to avoid this dilemma by holding that the duty of veracity, though not absolute, is to be given very great weight, and maybe overridden only in gravest cases.

PRINCIPLE OF CONFIDENTIALITY
Is the ethical principle that requires nondisclosures of private or secret information with which one is entrusted. Support for this principle is found in codes and oaths of nursing and medicine dated back many centuries. Confidentiality is the only facet of nursing care mentioned in the nightingale pledge. This oath has been recited for decades by graduating nurses: I will do all in my power to elevate the standard of my profession and will hold in confidence all personal matter committed to my keeping and all family affairs coming to my knowledge in the practice of my profession. The ability to maintain privacy in ones life is an expression of autonomy. The capacity to choose what others know about us, particularly intimate personal details, is important because it enables us to maintain dignity and preserve a measure of control over our own lives. Thus, maintaining confidentiality of patients is an expression of respect of persons and in many ways essential to the nurse-patient relationship. There are at least two basic ethical arguments of maintaining confidentiality: 1. Individuals right to control personal information and protect privacy. On one level, patients have the right to expect that personal and private information will not be shared unnecessarily among health care providers. On another level, nurses must keep in mind the number of people who have legitimate access to patients records. Information of a sensitive and private nature, care must be taken to avoid inadvertent breaches of confidentiality. 2. Utility If patients suspect that health care providers reveal sensitive and personal information, they maybe reluctant to seek care. Example: Diagnoses of mental illness, alcoholism, and drug addiction that, if revealed, could lead to public scorn, and subsequently discourage others from seeking care.

PRINCIPLE OF JUSTICE
Is the ethical principle that relates to fair, equitable, ad appropriate treatment in light of what is due or owed to persons, recognizing that giving to some will deny receipt to others who might otherwise have received these things. Within the context of health care ethics, the relevant application of the principle focuses on distribution of goods and services. This application is called DISTRIBUTIVE JUSTICE. Due to finite supply of goods and services, it is impossible for all people to have everything they might want or need .So a governing system formulate policies that deal with fair and equitable distribution of scarce resources.

DISTRIBUTIVE JUSTICE To each equally To each according to need To each according to merit To each according to social contribution To each according to the persons rights To each according to individual effort To each as you would be done by To each according to the greatest good to the greatest number There are those who believe that all should receive equally regardless of need. On the surface, nationalized health care systems would seem to meet this criterion, since all citizens are legible for the same services.

PRINCIPLE OF FIDELITY
Often related to the concept of faithfulness and the practice of keeping promises. Example: Society has granted nurses the right to practice nursing through the processes of licensure and certification. The process of licensure is one that ensures no other group can practice within the domain of nursing as defined by society and the

profession. Thus, to accept licensure and become legitimate members of the profession mandates that nurses uphold the responsibilities inherent in the contract with society. Members are called to be faithful to the society that grants the right to practice to keep the promise of upholding the professions code of ethics,to practice within the established scope of practice and definition of nursing, to remain competent in practice, to abide by the policies of employing institutions, and to keep promises to individual patients. Principle of fidelity relates to loyalty within nurse-patient relationship. It gives rise to an independent duty to keep promises or contracts, and is a basic premise of the nurse-patient relationship. Problems sometimes arise when there is a conflict between promises that have been made and the potential consequences of those promises in cases in which carrying them out will cause harm in other ways. Though fidelity is the cornerstone of trusting nurse-patient relationship, in every case, harmful consequences of the promised action should be weighed against the benefits of keeping the promise.

ETHICAL DECISION MAKING

Nurses constantly make decisions. We decide matters related to management of care, institutional policy, or when to collaborate or initiate referrals. Often we make decisions without conscious awareness of the process but have an innate sense of knowing what to do. The following presents a guide for ethical decision making. Moral/ Ethical Dilemmas Occurs when there are conflicting moral claims. Beauchamp and Childress (1984), a conflict can be experienced when there is evidence to indicate that a certain act is morally right and evidence to indicate that the act is morally wrong, but no evidence is conclusive. Example: A terminally ill patient, while most would think it is morally right to preserve life, many would believe it is morally wrong to prolonged suffering. A dilemma may occur when the agent believes that one or more moral norms, exist to support a course of action, and one or more moral norms exist to support another

course of action, and in two actions are mutually exclusive. Health care providers face this type of dilemma. Example: When they must decide who gets the critical care bed. Should they make the decision relative to who is most deserving, who arrives first, who can pay, or who has the best chance of survival? Conflicting moral claims can be said to occur, for example, between obligations, principles, duties, rights, loyalties, and so forth. Moral / Ethical problems Jametom (1984) describes three different types of moral problems: 1. Moral uncertainty- which occurs when the nurse identifies a moral problem but is unsure, of the morally correct action,when we are unsure what the moral principles or values apply,or when we are unable to define the moral problems. Example: A nurse caring for an older patient who is somewhat neglected . With little attention being given to the patients problem. 2. Moral dilemma- which occurs when two or more mutually exclusive moral claims clearly apply and both seem to have equal weight. 3. Moral distress- which arises when the nurse knows the morally correct action and feels a responsibility to the patient,but institutional or other restraints make it nearly impossible to follow through the appropriate action. Wilkinson (1987-88) added another category to Jametons typology: MORAL outrage- which occurs when someone else in the health care setting performs an act the nurse believes to be immoral.

Practical Dilemma Requires that choice be made between two alternatives that probably have no ramifications or consequences involving right or wrong. Examples: Practical dilemma could involve the decision to file an extension for the payment of ones income taxes in order to use the money for another purpose. The nurse who must work overtime, caring for a gravely ill patient. The nurse might perceive a dilemma because she made a promise to take her children to the circus. Though the nurse might say that her duty to the children conflicts with her duty to care for the patient, it can be argued that the duties are not of equal moral weight. Practical dilemma: The duty to keep the promise to her children is a practical duty that is grounded in self-interest. NONMORAL claims-often identified as claims of self-interest. Moral dilemma Any situation that requires a right or wrong decision about an action; an ambiguous proposition having to set solution. The ethnically correct course of action is in doubt. Example: Moral dilemma could arise if one is contemplating a deduction that is not quite legitimate to save money owed to taxes, in order to pay for childs medical expenses. Moral Distress A painful feelings and or psychological disequilibrium that occurs in situations in which the ethnically right course of action is known but cannot be acted upon. As a result, persons in moral distress act in manner contrary to their personal and professional values.

When moral distress occurs, there are no conflicting moral claims. The right action is clear, yet institutional or other restraints make it nearly impossible to pursue this course of action. Important consequences includes: .Stress .Burnout .Job satisfaction .Departure from the work environment and or nursing .Nurses loose their capacity for caring .Avoid patient contact .Fail to give good physical contact According to Hamri 2000 Moral Distress- A powerful impediment to nursing practice. Example: Nurses in the hurried atmosphere of a particular hospitals same day surgery report that they are expected to have sedated patients sign consent forms, recognizing that the physicians have often neglected to explain the scheduled procedures fully. The nurses know that this practice is one that does not respect patients rights to informed consent, yet they have neither personal authority nor access to decision-making channels, and therefore believe themselves to be powerless to make the necessary changes. Jameton 1984-points out that in situations of this sort,it can be personally risky for staff to criticize a practice that helps the hospital make end meet. Unrelieved moral distress over a period of time can erode the nurses values and affect confidence and self-esteem. Ethical decision making assures that moral claims hold greater weight than nonmoral claims. According to Cynda Hylton Rushton of John Hopkins University School of Nursing. Moral distress is a critical,frequently ignored problem in healthcare work environments unaddressed,it restricts nurses ability to provide optimum patient case and to find job satisfaction.Some nurses leave their positions and even the profession. When moral distress arises everyone should take steps to have it addressed.

Moral Outrage Occurs when someone else in the health care setting performs an act the nurse believe to be immoral (Wilkinson,1987-88). Nurses do not participate in the act, and therefore do not believe they are responsible for wrong, but perceive that they are powerless to prevent it. The nurse is more likely to be on the fringe of the immoral situation rather than directly involved. Example: The charge nurse in a medical surgical floor on the evening shift is working at the desk when the nursing supervisor comes to the floor to use the telephone to call a hospital administrator. The charge nurse overhears the supervisor describing a situation in which a patient was endangered when a physician insisted on performing a surgical procedure in a patients room. The surgeon was in a hurry and felt the patient would be safe, even though there were violations of patient privacy, informed consent and safety. The charge nurse has no involvement in the situation, but recognizes a grave moral problem.Whistleblowing may be a response to moral outrage.

Reference: Butts,Janie and Karen Rich (2006).Nursing ethics across the curriculum and into practice. Massachussetts: Jones and Barlett Publishers. Burkhardt,Margaret and Nathaniel,Alvita (2002).Ethics and Issues in Contemporary Nursing-Second edition.Delmar Thompson learning.

ATENEO DE DAVAO UNIVERSITY GRADUATE SCHOOL _____________________

AN OUTPUT PAPER ON ETHICAL PRINCIPLES AND ETHICAL DECISION MAKING _____________________

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN NURSING ETHICS _____________________

SUBMITTED TO:

MRS. VILMA LU COMODA, RN, MAN PROFESSOR

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SUBMITTED BY:

MARY ANTONETTE C. FERNANDEZ, R.N. ELVIRA S. MERCADO, R.N ZARLYN C. MIRAFLORES, R.N. EUNICE RIGONAN, R.N. STUDENTS

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JANUARY 20, 2007