NCM 108 – HEALTHCARE ETHICS
BIOETHICS and its Application in Various Healthcare Situations
BIOETHICS
• Study of ethical social, and legal issues that arise
in biomedicine and biomedical research
• It is multidisciplinary
• It blends philosophy, theology, history, and law
with medicine, nursing, health policy, and the
medical humanities
• Insights from various disciplines are brought to
bear on the complex interaction of human life,
science, and technology
PARTS OF BIOETHICS
• Medical Ethics – focuses on issues in healthcare
• Research Ethics – focuses on issues in the
conduct of research
• Environmental Ethics – focuses on issues
pertaining to the relationship between human
activities and the environment
• Public Health Ethics – addresses ethical issues in
public health
SEXUALITY AND HUMAN PRODUCTION
• Fertility of a couple – relates to the ability of a
man and woman to attain pregnancy and the
woman to sustain that pregnancy
✓ Advances in technology and medicine
have delivered considerable health
benefits but have also pushed the limits
of ethical practice in the field of human
reproduction
✓ Corresponding to such advances have
been semantic interpretations and
changes in terminology, which serve
both subjective scientific and moral
purposes
✓ For example, the biological definition of
human conception refers to fertilization
of an oocyte by a spermatozoon
resulting in a zygote—the beginning of a
new and distinct human life. It has been
argued that conception may also refer to
a pregnancy “beginning with
implantation of an embryo in a woman”,
promulgating an earlier and erroneous
but now widespread definition that
conception begins at implantation rather
than fertilization. In the age of assisted
reproductive technology (ART), one
definition of “fertility” is “the capacity to
establish a clinical pregnancy”.
✓ This definition allows for extracorporeal
manipulation of gametes and
fertilization, with conception and thus
clinical pregnancy attained at subsequent
implantation of the embryo in the
womb.
✓ The voracity of arguments on either side
of such definitions at tests to the
importance of fertility and bearing of
offspring in our society.
• Humanae vitae (Paul VI 1968) – where one of the
most profound intersections of theology and
reproductive medicine if found
✓ Regarded as the catalyst for the field of
natural family planning or what is
increasingly being referred to generically
as the Fertility Awareness-Based
Methods (FABMs)
✓ Has inspired the development and
spread of validated and morally
acceptable techniques such as:
 Billings ovulation method
 Creighton Model System
 Symptothermal method
 Marquette Method
• Paul VI – “any action which either before, at the
moment of, or after sexual intercourse, is
specifically intended to prevent procreation—
whether as an end or as a means”
✓ They find their rationale in the very
reasoning for which the church deems
contraceptive intercourse to be
inconsistent with conjugal love
• Theological Perspective – processes and actions
which intentionally separate these goods then
become morally elicit
• Positively Expressed – the unitive and
procreative qualities of a marriage are preserved
MARITAL ACT
• Fides:
✓ Faithfulness
✓ Intimacy
✓ Companionship
• Proles:
✓ Fruit of children
✓ Family
• Sacramentum:
✓ Sacramental
✓ Covenant nature
DOUBLE – EFFECT REASONING
• Clinicians – continually faced with balancing the
indications and benefits of a treatment
 NCM 108 – HEALTHCARE ETHICS
✓ Morally responsible for what they
directly intend and in that respect ought
not to do evil
✓ The treatment goal of the clinician needs
to be balanced with their responsibility
for ensuring that the risks are not
disproportionate or overly burdensome
✓ With respect to treatments that have
unethical or immoral dimensions, the
obligation of the clinician is ideally to
avoid cooperation with what is evil
• Ethics – person’s distinction between what is
right and what is wrong
• Moral – denotes reliance or consistency with
accepted teaching of the catholic church
• Aquinas 1274 – “moral acts take their species
according to what is intended, and not according
to what is beside the intention since this is
accidental”
CONDITIONS IN DOUBLE-EFFECT
REASONING
1. The action in itself from its very object must be
good or at least indifferent
2. The good effect and not the evil effect must be
intended
3. The good effect must not be produced by means
of the evil effect
4. There must be a proportionately grave reason for
permitting the evil effect
HORMONAL CONTRACEPTION
✓ Regarding the bioethics of contraceptives, the use
of hormonal treatment for a medical condition
does not present an ethical dilemma in itself
✓ Complicating hormonal medications, whether
delivered orally or via a drug-eluting device, is
their effect on the fertility of a woman and their
capacity for both contraception and
postconception termination
• Hormonal Contraception commonly presented
as:
✓ Oral Contraceptive Pill (OCP) –
containing progesterone with or without
an estrogen
✓ Implanted Etonogestrel-releasing device
✓ Intrauterine Contraceptive Device
(IUCD) – containing levonorgetrel
✓ Depot injection of
Medroxyprogesterone acetate
✓ Vaginal ring – containing etonogestrel
and ethinyl estradiol
MECHANISMS OF ACTION FOR HORMONAL
CONTRACEPTIVE FORMULATIONS:
1. Suppressing ovulation
2. Changing the characteristics of the cervical
mucus thus preventing or inhibiting sperm
transport to the fallopian tubes
3. Altering the maturation of the endometrium thus
potentially causing any conceptus formed to
unlikely to successfully implant (post-conception
effect – considered an induced preimplantation
abortion which is intrinsically ethically evil)
• IUCDs – also known to invoke an inflammatory
response which further inhibits sperm as well as
the ability of a conceptus to implant in the uterus
• Is the loss of life disproportionate to the good
that the woman is seeking to achieve?
✓ This will depend on whether there are
alternatives that do not involve the loss
of life
MALE FERTILITY INVESTIGATION
• Infertility – may result from female factors, male
factors and combined factors
• Woman – where most emphasis on infertility
investigation and management is directed
• Male investigation – necessary to ascertain the
presence of specific male infertility and to direct
further investigation for the woman
FERTILITY AWARENESS AND ASSISTING
CONCEPTION
• Optimal fertility health awareness – require
knowledge of the physiological signs of fertility
taught by the various agencies for FABM
• Restoration of fertility:
✓ Hormonal supplementation
✓ Surgical treatment of endometriosis
✓ Ovarian drilling
✓ Mechanisms to enhance ovulation
• Providing fertility awareness education:
✓ Fostering mutual respect
✓ Cooperation within couples
✓ Pointing toward the undeniable reality of
sexual difference and complementarity
• Fertility awareness – allows individuals and
couples to take responsibility for their fertility,
bringing with it an awareness for their bodies,
sensitive to symptoms of health and disease
✓ If woman is known to be ovulating
adequately, the intent of procedural
fertility management (such as ovulation
induction) is aimed toward conceiving a
pregnancy rather than restoring fertility
and may thus be deemed as formal
cooperation with the woman
✓ In further consideration of her individual
circumstances is warranted to ascertain
the balance of risk versus benefit of
treatment as well as natural law
 NCM 108 – HEALTHCARE ETHICS
principles regarding the morality of
intercourse within a couple’s relationship
ART: In Vitro Fertilization (IVF) and Gamete
Intrafallopian Transfer (GIFT)
• Dignitas Personae – technical interventions into
the procreative process should respect three
essential goods:
✓ The right to life and physically integrity
of the embryo from the moment of
conception
✓ The right to become a father or mother
only through one’s spouse in marriage
✓ That procreation should be “the fruit of
the conjugal act specific to the love
between spouses”
• It follows that any intervention that facilitates the
conjugal act in reaching its end is permitted, but
any action that substitutes the conjugal act is to
be excluded
Prenatal Adoption of IVF Embryos
• The fate of “spare” of abandoned embryos
created through IVF constitutes another moral
dilemma
• Catholic Church – rejected using these embryos
for research of for the treatment of disease
because that would involve treating the embryos
as mere “biological material” and result in their
destruction.
• It also asserts that proposals to thaw such
embryos without reactivating them and then
using them for research, as if they were normal
cadavers, would be unacceptable
DIGNITY IN DEATH AND DYING
• Ethical dilemmas faced in healthcare settings
often relate to issues of and attitude toward living
and dying
✓ “When does life begin?”
✓ “When does life end?”
✓ “How can we be sure that someone has
died?”
✓ “Who decides?”
LIFE
• Technology – stretched the boundaries and
clouded the waters surrounding life’s beginning
and ending
✓ Today, many low birth weight infants
and those with certain birth defects, who
would not have survived in prior eras,
survived with the support of machines,
medications, and surgical procedures. In
process, however, some babies are kept
alive only to die after months of
expensive treatment
✓ Others survive to face chronic health
problems with their associated financial,
emotional, and physical strains on
families and the health care system
✓ There is no definitive way to predict
which infants will have problems as they
grow and develop. Dilemmas arise
regarding how much effort to invest in
“saving” a few infants who have a high
probability of living only a short time or
with significant health problems
DEATH
• Death – become an unnatural event, frequently
associated with hospitals and other institutions,
surrounded by tubes, machinery, and heroic
efforts
✓ Determining when life ends has become
a critical issue related to use of
technology, prompting the involvement
of courts in decision making
✓ The general attitude, especially among
healthcare providers, is that death is the
enemy to be overcome or kept at bay for
as long as possible, regardless of the age
or health condition of the person
✓ Death is often viewed as a failure on the
part of the health provider
✓ Another reason that the topic of death
may be avoided is that discussing death
requires us to face issues of meaning in
life and anxieties and fears regarding our
own mortality
✓ Lack of discussing death is a possible
outcome may lead families and patients
to have unreasonable expectations and
false hopes of what the system can offer
✓ Demands for inappropriate
interventions, or accusations that not
enough was done, may arise from such
situations
✓ Patients and families need support in
recognizing and honoring their
responses, beliefs, and fears regarding
death. By facing our own issues about
death, we are better able to facilitate this
process with patients
✓ In many cultures, death is viewed as part
of our life cycle which comes in its own
time
✓ Health care focused on curing is
provided when there is reasonable hope
of benefit, but people recognize when it
is time for care to mean letting go and
facilitating the transition through the
dying process. In such cultures, dying
 NCM 108 – HEALTHCARE ETHICS
often occurs at home, surrounded by
family and friends
DYING
• Personal attitudes – prompt different
expectations and scenarios when we are faced
with decisions about heroic efforts and life-
sustaining technologies
✓ We must be aware of our own attitudes
concerning living and dying, as well as
the beliefs expectations of patients,
families, and other health care providers
✓ Such awareness alerts us to situations in
which there are differing attitudes
among the parties involved and provides
an opportunity for opening lines of
communication before a serious
dilemma arises
✓ It would be important for the nurse to
explore this area further with the patient,
and either communicate his wishes to
the physician or facilitate the patient’s
talking with the physician about his
wishes
✓ We must remember that dying is more
than a medical occurrence, it is a spiritual
process touching the individual, family,
and community
✓ Although medical interventions can
assist and support those in the dying
process, and separate people form their
families by actual physical barriers and
institutionalization
✓ Relieving suffering and supporting a
dignified death are important elements
of the nursing role
✓ Addressing patient needs may require
nurses to make decisions to go against
institutional policy regarding such things
as visitors and visiting hours, in order to
ensure that the patients not alone, or to
risk confrontations with physicians over
pain management or other aspects of
care
MEDICAL FUTILITY
• Ethical and legal arguments for initiating or
discontinuing life-sustaining treatments – based
primarily on the relative benefits and burdens for
the patient
✓ Although many healthcare professionals
feel reluctant to discontinue life-
sustaining treatments, most
philosophical and legal commentators
find no important ethical or legal
distinction between not instituting a
treatment and discontinuing treatment
already initiated
✓ Withholding or removing life-sustaining
in which the burden or harm has been
determined to outweigh the benefits is,
in essence, allowing the person to die as
a result of the natural progression of the
illness process
• Euthanasia – causing the painless death of a
person in order to end or prevent suffering
DO NOT RESUSCITATE ORDERS
• Cardiopulmonary Resuscitation (CPR) – an area
in which nurses have an active role in initiating or
withholding life-sustaining treatment.
✓ Considering whether to initiate CPR
with a patient requires attention to
professional, ethical, legal, and
institutional considerations
✓ Principles utilized to justify decisions
regarding resuscitation:
 Autonomy
 Self-determination
 Non maleficience
 Respect for persons
✓ The general practice regarding CPR is
that it must be initiated unless:
 It would clearly be futile to do
so
 The practitioner has specific
instructions not to do so
✓ The legal definition of do not
resuscitation (DNR) is not to initiate
CPR in the event if a cardiac or
pulmonary arrest
• DNR orders – written directives placed in a
patient’s medical record indicating that the use of
cardiopulmonary resuscitation is to be avoided
✓ DNR orders should be documented
immediately in a patient’s health care
record, nothing the reason the order was
written, who gave consent and who was
involved in the discussion, whether the
patient was competent to give consent or
who was authorized to do so, and the
time frame for DNR order
✓ The presence of DNR orders requires
nurses to become even more focused on
providing support and comfort
interventions and to ensure that there is
no reduction in the level of care for the
patient and the family
✓ DNR order means only that, in the event
of cardiac or respiratory arrest, there are
to be no attempts to resuscitate.
Presuming no arrest occurs, the patient
may recover from the problem
 NCM 108 – HEALTHCARE ETHICS
necessitating hospitalization and return
home
NURSING CONSIDERATIONS RELATED TO
DNR ORDERS
✓ Although it is generally considered the domain of
the physician to write a DNR order, nurses need
to be aware of the parameters surrounding such
orders
✓ In some states, persons with serious medical
conditions keep special medical order from
documenting end-of-life wishes posted in a
prominent place at home (or in the chart if the
person is in a long-term facility)
✓ This form specifies end-of-life wishes patients
under their care have DNR orders, and these
orders need to be documented clearly in he
patient’s chart, and perhaps at the bedside, and
reviewed periodically as the patient’s condition
changes
• Nurses are often the bridge between patient and
physician
✓ If a patient or appropriate surrogate
indicates to the nurse that desire to be
resuscitated and there is no order in the
chart, the nurse should document the
request in the patient’s chart and bring
this to explore the request with the
patient or surrogate and may need to
facilitate discussion of the issue between
patient and physician
✓ Orders should specify which
interventions are to be withheld, and
considerations regarding circumstances
in which they are to be withheld
✓ All persons involved in the care of the
patient need to know about the orders.
Since attitude affect one’s approach to
others, nurses need to reflect on their
own attitudes toward decisions regarding
withholding interventions, both general
and in particular situations
NURSING ROLES AND RESPONSIBILITIES
“All professional nurses have a responsibility to care for
their patients. There is no uncertainty and no ambiguity
surrounding the responsibility in the context of nursing
ethics” – Code of Ethics for Nurses (ANA, 2014)
NURSING ROLES
Traditional, common and most common roles of nurses:
• Care providers – provides direct care to patients
in a respecting, nurturing, comforting, caring, and
knowledgeable way
• Educator – increases patient knowledge through
information dissemination, encouraging healthy
lifestyles and practices and compliance to care
• Counselor – promotes the patient’s ability to
make sound medical decisions, assists in
developing new attitudes, feeling and behaviours
• Change Agent – takes the necessary actions to
educate and initiate change for the well-being and
the health of the society
• Researcher – takes the initiative to examine and
explore things affecting sensitive healthcare
issues
NURSES’ BILL OF RIGHTS
• Nurses – work with various people within the
family, community, and the entire nation
• American Nurses Association (ANA) – designed
the Nurses’ Bill of Rights based on respect,
ethics, dignity and autonomy
The nursing rights includes:
1. The right to practice to fulfil obligations within
the society
2. The right to practice according to professional
standards and legally authorized scopes of
practice
3. The right to work in an environment that is safe
and supports and facilitates ethical practice
4. The right to freely and openly advocate for
themselves and their patients, without retribution
ETHICAL RESPONSIBILITIES
• Respect for others – a nurse must respect the
dignity and value of patients and colleagues, treat
all person equally regardless of personal attributes
or medical condition
 The responsibility to always respect the
patient’s right to self-determination in
her medical care
• Commitment to patient – One of a nurse's
primary ethical responsibilities is to work with the
patient to provide care that maximally enables the
physical, emotional, and social well-being of the
patient.
 A nurse is also responsible for protecting
and advocating for patient safety and
rights
• Honesty and Self-Integrity – Nurses also have an
ethical responsibility to be honest with patients
and colleagues and to maintain self-integrity and
high personal moral standards.
 Nurses have a personal responsibility to
maintain professional competence and
strive towards personal and professional
growth so as to provide the best possible
care to patients
• Professional responsibilities – A nurse also has a
number of ethical responsibilities relating to the
profession of nursing and her specialty. One key
 NCM 108 – HEALTHCARE ETHICS
responsibility is to always strive to improve both
healthcare environments and conditions of
employment to maximize the quality of
healthcare delivery
 Nurses also have a responsibility to work
with the public and other medical
professionals to foster local school or
community, national and international
efforts to improve healthcare systems on
all levels.
PROFESSIONAL RESPONSIBILITIES
• Professional Responsibility – ethical and moral
obligations permeating the nursing profession
 These standards relate to patient care,
collaboration with other medical
professionals, integrity, morals and the
responsibility to effectuate social change
• Ethical Violations – could result in a loss of
license or discipline by the state nursing board
• Patient’s Interest – The best interests of the
patient are pre-eminent above any other concern
or bias held by the nurse.
 Nurses must always resolve conflicts of
interest in ways to ensure patient safety
and guard professional integrity. The
nurse’s duty to collaborate fully with the
entire treatment team, including doctors,
other nurses and specialists
• Advocacy and Responsibility – The nurse has a
duty to advocate for her patients. She must work
to advance the patient's legal rights, privacy
protection, and right to choose whether or not to
participate in medical research.
 As an advocate, the nurse must ensure
that she meets all qualification and state
licensure regulations prior to
participating in nursing activities and
must be vigilant against other colleagues
with impairments.
 At all times, nurses have the professional
duty to accept personal responsibility for
their actions and are accountable for
nursing judgement and action or
inaction. This accountability extends to
situations in which the nurse delegates
duties to a colleague or subordinate
• Values and Morals – The nurse has a duty of self-
respect and morality to herself as well as those
around her, including patients.
 Nurses must maintain constant
professional growth and commitment to
lifelong learning.
 Ethics rules - dictate that a nurse must
manifest a positive wholeness of
character, meaning her virtuous
character extends beyond the workplace
and into her personal life.
 Nurses are expected to be moral and
express wisdom, courage and honesty
 Nurses in a leadership roles must
provide employees an opportunity
grievances in a positive way and create
environments that foster ethical nursing
practices
• Community Education – nurses have an ethical
duty to spread knowledge and information about
health, wellness, and the avoidance of disease
 Nurses should advance the profession by
participating in community outreach
programs and civic activities related to
health care. Nurses have a duty to stay
abreast of national and global health
concerns, outbreaks, epidemics, and
infectious diseases
 A nurse must also stay educated about
vaccines, world hunger, pollution, lack
of access to health care, violations of
human rights, and the equitable
distribution of nursing services
• Perpetuation of Ethical Standards – Nurses have
a responsibility to maintain open and constant
discourse with colleagues about ethical issues.
 Nurses must affirm the values of the
profession to other members and carry
out collective adherence through
enrolment in professional associations.
Nurses must stay actively involved in
discussions and debates related to social
change and reform, particularly
pertaining to access to healthcare,
homelessness, and the stigma of illness.
ETHICAL DECISION MAKING
Each person makes decisions as part of everyday life.
Some decisions seem routine, such as what to have for
lunch or what to wear to work. Other decisions, like where
to go to college, which job to accept, or whether to marry,
call for more deliberation.
Moral/ethical decisions such as whether to abort a fetus
or when to discontinue life support are even more
complex.
Nurses constantly make decisions. We make decisions
about routine matters such as patient care management
and institutional policy. We also participate in decisions
about moral/ethical problems. Sometimes we have no
conscious awareness of our thought process but have an
innate sense of knowing what to do. At other times, we
grapple with decisions.
Ethical decision making is not as clear cut as decisions
made in other areas of life. Moral problems are complex.
 NCM 108 – HEALTHCARE ETHICS
They may include intricate human relationships among
disparate participants who have opposing opinions and
power imbalance. They incorporate a mix of values, risks,
benefits, and harms. The best solution is often obscure
and its ultimate outcome is unknown until the process
unfolds.
Nurses are involved in patient care situations imbued with
moral implications. Everyday, people in the health care
system make ethical decisions affecting life and death.
Research has shown that as many as 50% of nurses leave
the bedside because of moral distress. Nurses who are
informed, courageous, and involved in ethical decision
making are more likely to be satisfied with their work and
thus stay at the bedside.
ETHICAL DECISIONS
Four basic features constitute every type of decision:
• Problem
• Solution
• Action
• Outcome
PROBLEM
First, a problem must exist otherwise a decision is
unnecessary. Recall that a problem is a discrepancy
between the current situation and the desired state. A clear
statement of the problem is critical to finding a rational
solution
A statement of the problem has two parts:
• The current situation
• The desired state
SOLUTION
Second, there must be atleast two alternative solutions
from which to choose. If no course of action will affect
the outcome, there is no need to engage in decision
making-the outcome is inevitable.
• Uncertainties – elements that we can neither
control nor predict absolutely
There are important because they affect the outcome.
Uncertainties create angst among decision makers.
Accurately anticipating, controlling, and predicting
uncertainties assists with rational decision making
OUTCOME
Fourth, every implemented decision, combined with the
uncertainties, brings about an outcome. With decision
making, our goal is to move from the current situation to
the desired state.
When the goal and outcomes are the same, people
applaud the decision, even though uncertainties might
have altered the outcome
MAKING DECISIONS
As humans, we make decisions many times each day. Most
decisions follow a similar pattern, whether they involve
routine day-to-day problems or complex professional
ones
Depending upon the situation, the decision-making
process ranges from a subconscious one used for minor
routine problems to a sophisticated one based upon
specific principles
The pattern for most types of decision making includes
recognizing a problem, gathering data, comparing
options, using some criteria for weighing the merits of
each option, and making a choice.
Evaluation of outcomes or circumstances surrounding the
choice provides more data regarding the rightness of the
choice. Your evaluation of whether you made the right
decision provides information about the strength or
validity of the criteria you used to guide your decision, and
whether to use these same criteria to guide similar
decisions in the future.
NURSING PROCESS AND DECISION MAKING
As nurses, we commonly use the nursing process model
for decision making. Utilizing both logical thinking and
intuitive knowing, the nursing process is a deliberate
activity that provides a systematic method for the nursing
process.
• Nursing process - directs nursing practice,
standardizes nursing care, and unifies nurses.
Criteria used in making nursing care decisions derived
from areas such as:
• Knowledge of normal anatomy
• Physiology
• Psychology
• Pathophysiology
• Therapeutic communication
• Family dynamics
• Pharmacology
• Microbiology
• Nursing and other theories
• Human energy fields
• Familiarity with standards of acre and protocols
• Experiences related to what has worked in similar
situations
• Intuitive knowing
SCIENTIFIC PROCESS AND ETHICAL
DECISION MAKING
The process of decision making in ethics follows a
procedure that is similar to the scientific process.
"A comparison between the giving of good reasons in
science, which is called' explanation', and the giving of
 NCM 108 – HEALTHCARE ETHICS
good reasons in ethics, which is called' moral justification',
reveals striking procedural similarities bordering on
identity."- Gibson 1991.
Gibson notes similarities between the scientific process of
explanation, which moves from observation-hypothesis-
law-theory, and the moral justification process of ethics,
which moves from assessed ethical dilemma-rule-
principle-theory.
A strong knowledge base regarding societal rules, ethical
principles and theories, and professional codes and
standards areas important to making ethical decisions as
knowledge of principles related to physical, psychological,
social, and human science is to other nursing judgments.
APPROACHING ETHICAL DECISIONS
Nurses who are able to effectively engage in ethical
decision making are less likely to experience moral distress
and leave the bedside. Research has shown that many
nurses are unprepared to be equal participants in ethical
decision making
You should make an effort to articulate and examine your
core values and their relationship to nursing and
institutional standards
POSITIVE ATTRIBUTES OF AN EFFECTIVE
ETHICAL DECISION MAKER
You can cultivate the following decision attributes that
will prepare you to assume the decision-making role:
• Moral integrity – binds all of a person’s moral
virtues into a coherent package; it creates
wholeness and stability of character that leads to
trustworthiness.
 It is integral to affective ethical decision
making. The person with moral integrity
does not hold stubbornly to one
position, but encourages a climate of
mutual respect and reasoned discourse;
however, will not compromise beyond a
certain point.
• Sensitivity, Compassion, and Caring – nurses
work intimately with patients-they hear what
patients say and understand the meaning.
 They perceived the circumstances,
attitudes, and feelings of others. They
intimately know about suffering from
touch, sight, smell, and sound. Interests
of patients become their own.
• Responsibility – as a sense of duty to the patient,
an obligation to do whatever is necessary, within
reason, to care for the patient or solve a problem.
 A nurse with responsibility, sensitivity,
compassion, and caring will recognize
moral problems, understand them from
a human perspective, and accept a duty
to work actively toward their solution.
• Empowerment – the capacity of people to be
active participants in matters that affect them.
 Empowerment suggests that a person
has self-confidence that he or she can
effect changes. It includes courage and
an exercise of power. Empowerment is
an essential attribute for those making
ethical decisions. It creates positive
action flowing from sensitivity,
compassion, caring, and responsibility.
• Patience and Willingness to Deliberate – They
work to clarify and articulate their views and
relate them to a framework of values
 The nurse must listen and be patient,
able to live with vagueness, confusion,
uncertainty, and paradox. The nurse
should provide a safe environment and
gently assist patients, families, and
colleagues as they work through the
ethical decision-making process.
EMOTIONS AND ETHICAL DECISIONS
Many approaches to ethical decision making describe a
primarily cognitive process in which emotions are
subordinated to reason. In a holistic view of people,
however both thinking and feeling are credible ways of
knowing, each having a legitimate role in ethical decision
making
Callahan (2000) – suggests that heart and mind should not
be viewed as antagonistic in the moral arena; rather both
reason and emotion should be active and in accord as we
come to an ethical decision
Noting that emotions should influence reason while
reason is monitoring emotion she describes emotions as
personal signals providing information regarding both
inner processes and interactions with the environment.
It is important to appreciate not only what you think
about what is right or wrong in a situation, but also what
you feel in relation to the circumstances and decision to
be made. The goal is to have head and heart in harmony
as the decision is made.
ETHICAL DECISION-MAKING MODEL
We approach ethical decision-making with a problem-
solving frame of reference and sensitivity to the human
story. Similar to both the nursing process and scientific
inquiry, ethical problem-solving includes a number of
steps.
• Ethical Decision-Making – a process that
overlays other dynamic biological, psychological,
and social processes-layer upon layer. Physical
conditions change, opinions change, knowledge
evolves, and time passes.
 Articulate the problem
 Gather data
 NCM 108 – HEALTHCARE ETHICS
 Explore strategies
 Implement the strategy
 Evaluate outcomes
ARTICULATE THE PROBLEM
The first step in the decision-making process is to clearly
articulate the problem. When you identify the problem,
you will also clarify the goal, since a problem consists of a
discrepancy between the current situation and the desired
state (goal).
Ethical decision-making begins when someone suggests
that there is a moral problem. If the moral problem is such
that it requires a decision, it is in tolerable and should be
relatively easy to identify. Once you name the current
situation, there is a logical flow towards describing one or
more desired goals.
GATHER DATA AND IDENTIFY
CONFLICTING MORAL CLAIMS
When an ethical problem occurs, gather information or
facts in order to clarify issues. Identification of the
conflicting moral claims that constitute the ethical
dilemma is the first part of the process. You should
examine the situation for evidence of conflicting
obligations, principles, duties, rights, loyalties, values, or
beliefs.
Additionally, data provide an understanding of the ethical
components, principles of concern, and the various
perceptions of issues and principles by those involved in
the situation. You must pay attention to societal, religious,
and cultural values and beliefs.
Identify the key persons involved in the decision-making
process and delineate each person's role. Determining the
rights, duties, authority, context, and capabilities of
decision makers is a critical component of the process.
Identification of the principle decision-maker is
sometimes all that is needed to facilitate the process.
Recognition that one has the legitimate authority to make
an important decision is an empowering event. Once the
principal decision-maker is identified, the roles of the
other participants can be explicilty outlined
Knowledge of moral development and ethical theory may
provide a helpful framework for understanding
participants and their perspectives and responses in the
process.
Assess how those involved fit into paradigms of moral
development. It is valuable to recognize, for instance,
whether the principal decision-maker is at a
developmental level in which choices reflect a desire to
please others, thus susceptible to choosing an alternative
solely on the basis of seeking approval.
EXPLORE STRATEGIES
Having determined the desired outcomes, participants
should identify possible alternative strategies. Various
options begin to emerge through the assessment process.
Participants must consider legal and other consequences
They must also determine which alternatives best meet the
identified goals and fit their basic beliefs, lifestyles, and
values. This process helps to narrow the list of acceptable
alternatives
It is critical to eliminate all unacceptable alternatives and
begin the process of listing, weighing, ranking, and
prioritizing those that are found to be acceptable.
Participants must make a choice among options with both
head and heart; taking time to dwell with remaining
alternatives, recognizing that there is rarely a good
solution. Once the selection is made, the decision-makers
must be willing to act upon the choice.
IMPLEMENT THE STRATEGY
Taking action is the major goal of the process, but can be
one of the most difficult parts of the process.
It can stir numerous emotions laced with both certainty
and doubt about the rightness of the decision.
Participants must be empowered to make a difficult
decision, setting side less acceptable alternatives.
• Be empowered to implement a difficult situation
• Give oneself permission to set aside less
acceptable alternatives
• Be attentive to the emotions involved in this
process
EVALUATE OUTCOMES OF ACTIONS
After acting upon the decision, participants begin a
process of response and evaluation. As in all decision-
making, reflective evaluation sheds light on the
effectiveness and validity of the process. Evaluate the
action in terms of the effects upon those involved.
• Has the ethical dilemma has been resolved?
• Have other dilemmas emerged related to the
action?
• How has the process affected those involved?
• Are further actions required?
NCM 108 – HEALTHCARE ETHICS