Seminar on bioethical dilemma in nursing profession

SEMINAR ON BIOETHICAL
DILEMMAS IN NURSING
Moderator Presenter
Ms. Kalpana Silwal Ms. Rama k. Joshi
Associate Professor MN 1st year student
School of Nursing, CMC 10th Batch, CMC
2

Objectives
At the end of the seminar, participants will be able to:
Define ethics
Expalin the code of ethics
List out the principles of ethics
Enlist the ethical theories
Define bioethics
Explain the historical background of bioethical dilemma
Explain the common bioethical issues
3

Objective contin…….
Define dilemma
Define ethical dilemma
Define bioethical dilemma
State the common bioethical dilemma in nursing
 Explain Research related findings related to bioethical
dilemmas
Explain the ethical decision making models
Describe case study related to bioethical dilemmas using
bioethical decision making model

Ethics
•The term ‘ethics’ originate from Greek word ‘Ethos
'meaning ‘custom’.
•Ethics is a branch of philosophy that concern the
distinction between right and wrong based on a
body of knowledge, not just based on right or
wrong.

Ethics
According to medical dictionary;
Ethics is a branch of philosophy dealing with values
pertaining to human conduct, considering the
rightness and wrongness of actions and the goodness
or badness of the motives and ends of such actions.
6

Nursing ethics contd
Nursing ethics
According to medical dictionary
is the value and ethical principle governing nursing practice,
conduct and relationship . The code for nurses , adopted by
the ANA in 1950 and revised periodically, is intended to the
ethical discharge of the nurses responsibility.

Code of ethics
The ICN code of ethics for Nurses has four principlal elements
that outlines the standards of ethical conduct.
An international code of ethics for nurses was first adopted by
the international council of nurses (ICN) in 1953.it has been
revised and reaffirmed at various times since, most recently
with this review and revision completed in 2012)

Principle Of Ethics
Principle based ethics is a systematic method of resolving
ethical problems that involves reflection on general
principles of ethics. These principles are also applicable in
health care and have its implications in nursing. They are
as follows:
•Autonomy
•Informed consent
•Justice

Contd………… Ethical Principal
•Veracity
•Accountability
•Confidentiality
•Beneficence
•Nonmalefficence /do no harm
•Fidelity

Ethical legal issues in Nursing profession
1. Confidentiality and right to privacy
all information regarding the patient belongs to
that patient. A nurse who gives out information
without authorization from the patient or from
the legally responsible guardian can be held
liable.

Ethical issue contd
2. Priviledged information
some information divulged to a nurse by patient
in the course of the professional relationship may
be considered priviledged. That means ,if the nurse
is called upon to testify in court that information
need not be divulged.

Ethical issue contd
3. Informed concent
every individual has the right to make ones own
decisions in the right to consent to or to refuse
medical treatment.

Ethical issue contd
4. Emergency care
if a true emergency exists consent for care is considered
to be implied. The law holds that if a reasonable person
were aware that the situation was life threatening, he/she
would give consent for care .thus policy often states that
at least two physician must examine the patient and
concur that there is an emergency.

Ethical issue contd
5.Defamation of character
Defamation of character involves communication
that is malicious and false. Written defamation is
called liable,oral defamation is called slander. E.g
the patient is alcoholic,or patient is rude and
dominating.

Ethical issue contd
6.False imprisonment:
making a person in all lace against his wishes is
false imprisonment. The person can be forced to stay
with either physical means or verbal means.

Bioethics Contd..
•It is derived from Greek bio-life and ethicos moral.
•The science/art that aims at identification, analysis,
and resolution of the ethical issues in almost any
field that is related to human life and health
(Definis, 2016).
18

Historical Background
•The term Bioethics (Greek bios, life; ethos, behavior)
was coined in 1926 by Fritz Jahr in an article about a
"bioethical imperative" regarding the use of animals
and plants in scientific research.
•In 1970, the American biochemist Van Rensselaer
Potter used the term to describe the relationship
between the biosphere and a growing human
population. 19

Historical Background Contd..
•Potter's work laid the foundation for global ethics, a
discipline centered around the link between biology,
ecology, medicine, and human values.
•It was later used to refer a study of the ethical issues
arising from health care, biological and medical
sciences.
•It is a major area in applied ethics.
20

Bioethical Issues
•Bioethics involves issues relating to the beginning
and end of human life, all the way from issues
relating to in-vitro fertilization and abortion to
euthanasia and palliative care.
•Other issues that confront nurses are those matters
related to life-supporting measures and to the rights
of patients.
21

Common Bioethical Issues
1. Related to Birth:
• Genetics
• Human reproductive technology
(in-vitro fertilization, artificial
insemination, surrogate
motherhood)
• Abortion
• Cloning
• Neonatal ethics
• Contraception
22

Bioethical Issues Contd..
2. Related to life events:
•Allocation of medical resources
•Informed consent
•Organ and tissue donation, transplantation
•Substance abuse
•Aged care
23

3. Related to death:
•Euthanasia
24

Abortion
•Abortion is a highly publicized issue about which
many people, including nurses, feel vey strongly.
•Debate continues pitting the principle of the sanctity of
life against the principle of autonomy and women’s
right to control her own body. This is an especially
volatile issue because no public consensus has yet been
reached.
25

End of Life Care
•Some people want everything possible done to
maintain life and others do not.
•Competent adults have the legal right to refuse or have
withdrawn any treatment.
•Often family members of the dying patient cannot
make end of life decisions or have conflicting desires
about the care that should be provided.
26

•Advance directives and living wills allow people to
indicate their desires about the end of life care.
Information about advance directives are mandated
for individuals admitted to health care facilities.
•Nurses are often called upon to present information
and provide explanations.
27

Euthanasia
Active euthanasia involves the administration of a
lethal agent to end life and alleviate suffering.
Passive euthanasia involves the withdrawal of extra
ordinary means of life support, such as removing
ventilator support and withholding resuscitation.
28

•The concept of death with dignity and the concerns
about quality of life have brought about right-to-die
legislative actions.
29

Surrogacy
•Surrogacy arrangement is the carrying of a pregnancy
for intended parents. There are two main types of
surrogacy: Gestational and traditional.
30

Ethical issues that have been raised with regards to
surrogacy include:
•to what extent should society be concerned about
exploitation, commodification or coercion when
women are paid to be pregnant,
•to what extent is it right for society to permit women to
make contracts regarding the use of her body,
31

•is contracting for surrogacy more like contracting for
employment, or more for prostitution or for slavery?
•what does motherhood mean? Is it possible to socially
or legally conceive multiple modes of motherhood?
•should a child born via surrogacy have the right to
know the identity of any/all of the people involved in
that child’s conception and delivery?
32

Bioethical Issues Contd…
Organ donation and transplantation
•Ethical issues related to organ transplantation include:
the allocation of organs,
the selling of body parts,
the involvement of children as potential donors and
recipients, and
cloning for manufacture of organs.
•In some situation religious beliefs may be a source of
conflict. 33

Allocation of Health Resources
•Allocation of health care goods and services,
including such things as organ transplants, the
service of medical specialists, and care involving
expensive technology has become an especial issue
as medical costs continue to rise.
34

•Access to health care is limited to a segment of
population. Increasing people’s access to health care
is costly, however, and makes decision about
providing and financing health care difficult.
•An ethical argument arises as to whether health care
is a right or a privilege.
35

Dilemma Contd..
According to Oxford Dictionaries,
Dilemma is a situation in which a difficult choice has
to be made between two or more alternatives,
especially ones that are equally undesirable.
37

Bioethical Dilemmas
•Bioethical dilemma are the situations that pose a
choice between perplexing alternatives in the
delivery of health care because of lack of a clear
sense of right or wrong.
38

Common Bioethical Dilemma in Nursing
Honesty vs. selective information
Science vs. spirituality
Healthcare needs vs. resource allocation
Autonomy vs. beneficence
Dilemmas surrounding minors
39

Contd..
Honesty vs. Selective Information
In some cases, families choose to withhold
information about a patient’s medical condition to
avoid causing them emotional distress. How does a
nurse decide what information to give the patient?
40

Contd..
Science vs. Spirituality
Sometimes, the personal or religious beliefs of a
patient may clash with science-based empirical
knowledge.
A patient’s right to make their own choices/decisions
must be carefully balanced against a nurse’s
responsibility to provide them with the best care.
41

Contd..
Healthcare Needs vs. Resource Allocation
A large number of medical facilities have scarce
resources which puts patients at risk for not getting the
care they need. These resources range from medical
equipment to healthcare staff.
42

Common Bioethical Dilemma in
Nursing Contd..
Autonomy vs. Beneficence
Nurses are required to administer prescribed
medicine, but patients, at the same time, can refuse
them.
Patient autonomy can go against medical directives,
despite clearly defined needs. Patients have a right to
refuse all medical care. 43

Common Bioethical Dilemma in
Nursing Contd..
Dilemmas surrounding Minors
This is a particularly tricky area because not only do
nurses have to consider the best interests of the minor
patient, but they also have to respect the wishes and
beliefs of the child’s parents.
44

Bioethical Decision Making Models
1. A Seven Step Guide to Ethical Decision Making
(Michael Davis, 1999)
2. Ketefian’s ten step basic model for bioethical
decision making, (1997)
3. Character-Based Decision-Making Model
45

Bioethical Decision Making Models Contd…
4. Calabro's Participative Ethical Decision Making
Model
5. Thompson, J. & Thompson, H., bioethical decision
making for nurses (1985).
46

Thompson, J. & Thompson, H., bioethical
decision making for nurses (1985).
•Step One: Review situation to determine health
problems, decision needed, ethical components and
key individuals.
•Step Two: Gather additional information to clarify
situation.
•Step Three: Identify ethical issues in the situation.

Contd..
•Step Four: Define personal and professional moral
positions.
•Step Five: Identify moral positions of key individuals
involved.
•Step Six: Identify value conflicts, if any.
•Step Seven: Determine who should make the decision.

Contd..
•Step Eight: Identify range of actions with anticipated
outcomes.
•Step Nine: Decide on a course of action and carry it
out.
•Step Ten: Evaluate/review results of decision/action.

Case study: an ethical dilemma involving a dying
patient.
• Nursing often deals with ethical dilemmas in the clinical
setting. Example of case are as follows :
• A 20-year-old, pregnant, Black Hispanic female presented to
the Emergency Department (ED) in critical condition
following a single-vehicle car accident.
• She exhibited signs and symptoms of internal bleeding and
was advised to have a blood transfusion and emergency
surgery in an attempt to save her and the fetus.

Case study Contd……..
 She refused to accept blood or blood products and rejected
the surgery as well.
Her refusal was based on a fear of blood transfusion due to
her belief in Bible scripture.
 The ethical dilemma presented is whether to respect the
patient's autonomy and compromise standards of care or
ignore the patient's wishes in an attempt to save her life.

Case study using Thompson ten step
model
Step One: Review situation to determine health problems,
decision needed, ethical components and key individuals
Upon her arrival in the ED, Juana was alert and oriented to
person, place, and time and had a Glasgow Coma Scale of
15/15.
Her initial complaints were lightheadedness, weakness, left
shoulder pain, and severe abdominal cramping that started
immediately following the car accident.
She had a past medical history of sickle cell disease and no
previous pregnancies.

Case study contd
•Her lungs were clear bilaterally.
•Juana's heart rate was 90 beats per minute (bpm),
her respiratory rate was 28, and her initial blood
pressure (BP) was 130/80, and fetal pulse rate was
90.
• Once the cervical spine films were taken and the
flat board was removed, her BP reflected orthostatic
changes of 100/60 and pulse of 120 bpm.

Case study contd………….
•Diagnosis and interventions Juana was placed on a
100% nonrebreather mask.
•Peripheral intravenous lines were started bilaterally
to replace fluid loss that was indicated by the change
in vital signs.
•It was suspected that she was bleeding internally
into her thoracic or abdominal

Case study cont……
Step Two: Gather additional information to clarify
situation.
 The second step involves making sure that health team
understands correctly what Mrs. Juana has told , and making a
determination whether additional information is needed.

Case study contd…………….
In Juana's case, her decision to refuse the blood transfusion
had the desired outcome of allowing her to remain true to her
religious beliefs.

Case study contd…..
• Step Three: Identify ethical issues in the situation
• The major ethical dilemma was that by honoring the patient's
autonomy and religious beliefs, the physicians and
interdisciplinary team were faced with compromising their
moral duty to administer professional care in accordance with
established standards (Ghua &Tham, 2006).

• A brief review of the literature of Nursing Gollection II: Lippincott
Nursing Journals (from Ovid) and GINAHL databases for the past
5 years found no evidence to support best practice for a Jehovah's
Witness who is pregnant and has experienced blunt trauma.
• Healthcare providers faced with this situation have sometimes
attempted to obtain court orders that would overrule the patient's
decision and result in her submitting to recommended medical
treatment.

Case study contd….
• Step Four: Define personal and professional moral positions.
Healthcare providers faced with this situation have sometimes
attempted to obtain court orders that would overrule the patient's
decision and result in her submitting to recommended medical
treatment.
• For example, the Illinois Supreme Gourt {IWinois u. Brown. 1996)
upheld a mother's decision to refuse blood transfusions even
though they were vital for both the mother's and fetus' survival.

• The Patient's Bill of Rights states that the healthcare
providers' responsibility is to give patients accurate
information and that patients must consent to treatment (New
York State Department of Health, 2008).
• This is consistent with the Federal government's
recommendations to create guidelines that assure healthcare
quality and to reaffirm the critical role consumers play in
safeguarding their own health, (United States Department of
Health and Human Services, 1999).
• Nursing practice is governed by the patient's right to
autonomy rather than her religious beliefs (Levy, 1999)

Case study contd……
• Step Five: Identify moral positions of key individuals involved.
• Nurses draw from the code of ethics to reflect upon and
understand the person's perspective, and to honor her wishes.
"The nurse provides services with respect for human dignity and
the uniqueness of the client, unrestricted by considerations of
social or economic status, personal attributes or the nature of the
health problem" (ANA, 2001, p. I).

Step Six: Identify value conflicts, if any.
• To respect the patient's decision and honor her dignity,
supportive care was provided to the patient in an effort to
save her life, while at the same time respecting her wishes.
• The ANA Code of Ethics supports the point of view that
healthcare providers should respect patients' wishes and
decisions despite their own personal beliefs (ANA, 2001).
• Applying an etinical decision process Looking through the
lens of virtue ethics, the caregivers focused on Juana's
autonomy and her right to choose what she perceived best
in spite of the possible outcomes

• Step Seven: Determine who should make the decision
• Juana was a competent, pregnant woman who made
informed decisions not to receive blood transfusions or a
caesarean section.
• Based on virtue ethics, the healthcare providers respected
the patient's autonomy by reflecting on and honoring the
decision of the patient and her husband based on her
religious values and beliefs.
• The healthcare providers also drew on the principle of
beneficence, which centers on promoting the well-being of
others. In this case, the wellbeing was not physiological but
spiritually oriented..

Case study contd……
• Step Eight: Identify range of actions with anticipated
outcomes.
• The physician then recommended the use of alternative
blood products.
• Juana insisted that this was also against her religion and she
refused the alternative treatments being offered.
• According to Juana and her husband, both believed that if
she accepted the blood transfusion or blood products she
would no longer be a Jehovah's Witness and would be
condemned to hell.

Contd …… case study
• The husband then presented the physician with Juana's
blood card, created by the Watchtower Bible and Tract
Society, the governing organization of Jehovah's Witnesses.
• The card stated her advance directives, including the
prohibition of blood and blood products. The beliefs of
Jehovah's Witnesses stem from their interpretation of
passages from the old testament of the Bible, which they
believe is the inspired word of God (Watchtower, 2004).

Case study contd…
She went into labor and delivered a stillborn baby boy She
was immediately transferred to the intensive care unit where,
despite continued aggressive attempts to stabilize her, she
went into cardiac arrest and died.

Case study contd………
• Step Nine: Decide on a course of action and carry it out.
• The caregivers focused on Juano's autonomy and her right to
choose what she perceived best in spite to the possible
outcomes. " centers on the patient's autonomy.
• Actions and character are intertwined, and the ability to act
morally is contingent on one's moral character and integrity.

Case study contd……..
Step Ten: Evaluate/review results of decision/action.
• Healthcare providers should practice beneficence and non-
maleficence without imposing their beliefs as to the right
thing to do.
• More explicit and universal guidelines would benefit both
patients and providers when faced with similar ethical
dilemmas.

Conclusion
•One of the systematic approaches available to nurses
is the ethical decision-making model presented here.
•Nursing is a profession that requires special
knowledge and skills; ethical decision-making is one
of the skills that nurses use daily.

Conclusion Contd..
•Nurses who have a clear understanding of the key
ethical principles that guide ethical decisions and a
framework for ethical decision-making that is easily
used in their particular work place, can confidently
choose a course of action with a positive outcome.

References
•Bhattarai, S. (2010). Trends and Issues in Nursing (First
ed.). Kathmandu: Makalu Publication House.
•Bioethics. Retrieved from https://www.merriam-
webster.com/dictionary/bioethics
•Dilemma. Retrieved from
https://en.oxforddictionaries.com/definition/dilemma
•Ethics. Retrieved from https://medical-
dictionary.thefreedictionary.com/medical+ethics

Reference Contd..
•Pandey, K., & Bhandari, B. (2073). A Text Book of
Nursing Trends and Issues (First ed.). New Plaza,
Putalisadak, Kathmandu: Samiksha Publication
Pvt.Ltd.
•Potter, P. A., & Perry, A. G. (2007). Basic Nursing:
Essential for Practice (Sixth ed.). New Delhi, India.

Reference Contd..
• Ulrich, CM., Taylor, C., Soeken, K., O’Donnell, P
(2010). Everyday Ethics: Ethical Issues and Stress
in Nursing Practice. Journal of Advanced Nurses,
17(8).Retrieve from
http://www.bioethics.net/journals/ajob-volume-17-
issue-8/

Reference contd…..
• Case study: an ethical dilemma involving a dying patient
Article in The Journal of the New York State Nurses'
Association · March 2008 Source: PubMed CITATION 1
READS retrieve from
https://www.slideshare.net/homeworkping3/59058785-
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Seminar on bioethical dilemma in nursing profession

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