Critical thinking, ethical decision making and the nursing process

Critical thinking- systematic way of thinking based on a body of knowledge plus examination of all available information

SKILLS NEEDED IN RATIONAL THINKING

Interpretation- to determine significance of data
Analysis- to identify patient problems
Inference- to draw conclusions
Explanation- to justify actions or interventions used to address patient problems
Evaluation- to determine whether outcomes have been or being met
Self-regulation- to examine the care provided and adjusting the interventions as needed

COMPONENTS OF CRITICAL THINKING

Ask questions
Gather as much information as possible
Validate the information
Analyze the information
Draw on past experiences
Maintain a flexible attitude
Consider available options
Formulate decisions

ETHICS VS MORALITY
Ethics is adherence to moral beliefts
Morality is adherence to informal personal values

ETHICS THEORIES
Teleologic theory or consequentialism- fpcus on end/ consequence
Example: utilitarianism- “greatest good for the greatest number”
Deontologic or formalist- ethics principles are independent of the ends/consequence

APPROACHES TO ETHICS
Meta-ethics- understanding the terminology and concepts used in ethics
Applied ethics- a specific discipline identifies ethical problems within that discipline’s practice

MORAL SITUATIONS
Moral dilemma- 2 or more principles are conflicting
Moral problem- one of 2 conflicting principles are dominant
Moral uncertainty- cannot determine the moral issue but is sure there is something wrong
Moral distress- knows what is right but institutional constraints stops from doing what is right

COMMON ETHICAL PRINCIPLES

Autonomy- self-rule; individual rights, privacy and choice; can choose without external constraints
Beneficence- duty to do good and active promotion of benevolent acts, may include nonmaleficence
Confidentiality- privacy; ex: family members cannot be used as translators, must use translation services, ex: computer-
based technologies and people’s access to information
Double effect- produces both good and evil effects; all four criteria must be followed (GIAB rule)
1. The action itself is good or morally neutral
2. The agent sincerely intends the good and not the evil effect
3. The good effect is not achieved by means of the evil effect
4. Proportionate balance of good over evil
Fidelity- promise keeping, includes explicit and implicit promises
Justice- like cases should be treated alike; distributive justice- refers to distribution of benefits and burdens based on
various criteria that may include equality, individual need, individual effort, societal contribution, individual merit, legal
entitlement; retributive justice- distribution of punishment
Nonmaleficence- duty not to inflict harm, also to prevent and remove harm
Paternalism- intentional limitation of another’s autonomy (like nonmaleficence over autonomy)
Respect for persons- frequently synonymous with autonomy, treat people so they can make their own choices
Sanctity of life- life is the highest good, all forms of life should be more important than external factors
Veracity- tell the truth and not lie

TYPES OF ETHICAL PROBLEMS IN NURSING

Confidentiality- ex: family members cannot be used as translators, must use translation services, ex: computer-based
technologies and people’s access to information
Restraints- includes physical and pharmacologic measures, may breach autonomy and cause maleficence
Trust issues- veracity; ex: use of placebos, nonrevealing of diagnosis; revealing diagnosis to people other than patient
Refusing to provide care- ex: conflict of personal values, fear of personal injury, provide care regardless of patient
background
End-of-life issues- ex: pain control, DNR orders, life support measures and administration of food and fluids

PREVENTIVE ETHICS
- Choose the lesser of 2 evils
Patient self-determination act of 1991- concept of advanced directives
Advanced directive- ex: living will are in most cases, limited to terminal illnesses
Another ex: durable power of attorney
Ethics committees- policy making, educational or consultation purpose

Source: Brunner and Suddarth Medical-Surgical Nursing