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Ethics & Legal Issues for Nursing

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Human Dignity and Ethical Decision Making in Nursing

NurseEthical dilemmas in health care today present new and complex issues for the profession of nursing. Since the early Christian era, nursing has a long and illustrious history in responding to the forces of cultures and societies that threaten the dignity of the human person be it related to illness, health care inequities, discrimination, privileged allocation of resources, limited access to health services, or the application of unjust social policies. Defending and protecting the dignity, freedom, and autonomy of the human person is nursing’s intrinsic, indelible, and irrefutable commitment to caring for persons living in a world order where the intrinsic dignity of all persons may be at risk.

The Doctrine of Human Dignity

Through the doctrine of intrinsic human dignity, the central moral principle in health care, we can come to a fuller understanding of the ethical issues in the multiple domains of nursing and how our response to them protects and affirms the dignity and freedom of the human person.

Kant, a German philosopher, has been credited with providing our current understanding of human dignity. In his Metaphysics of Morals, Kant (Gregor, 1996) states,

A human being is regarded as a person, that is, as the subject of a morally practical reason, and is exalted above any price; for as a person he is not to be valued merely as a means to the ends of others or even to his own ends, but as an end in himself, that is, he possesses a dignity (an absolute inner worth) by which he exacts respect for himself from all other rational beings in the world. (p. 186)

This absolute inner worth is intrinsic dignity; that exalted level of value that is present in every person who has even been born simply because the person is human. No authority of any kind, of any nation, of any laws, or organization, or any illness, or station in life can ever obliterate intrinsic dignity from the character of the human person.

A Model for Making Ethical Decisions in Nursing

Philosophical and theological frameworks, models for ethical decision making, and professional codes of ethics are well established in the professional literature and are readily applied in nursing practice. Although the nursing profession does not advocate for one distinctive framework, the American Nurses Association’s Code of Ethics (2001) is the most frequently cited. Its very first article states,

The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. (p. 7)

Complimenting an ethical framework and its methodological application in nursing is the nursing process, which provides a systematic method for identifying health care and nursing needs of patients bringing some resolution to them. The examination of actual and potential ethical issues in health care and nursing that affect the patient, family, community, organization, or society benefits from the same rigorous investigation and analysis found in the nursing process. Commitment to evidence-based practice and to caring for the whole person (and not the disease alone) requires that the identification and analysis of ethical issues in patient care be systematically integrated into every step of the nursing process.

The following protocol, designed by the ethicists at the Center for Clinical Bioethics at Georgetown University (1991), focuses on the protection and affirmation of the dignity of the patient and the clinician as ethical issues in health care are examined and resolved. The steps of the protocol, applicable as well to the analysis and resolution of organizational ethical issues, are briefly outlined below:

  1. What are the facts with this patient? Diagnosis, prognosis, therapeutic options, chronology of the occurrence of clinical events, biography of the patient (age, gender, family, ethnicity, culture, career, etc.), decisional capacity and informed consent, who is the decision maker (i.e., the patient or the health care proxy), current clinical setting, time constraints (health status; identification of decision makers), and existence of a some form of advance directive and a health care proxy who is readily available, competent, and understands the responsibilities of the role.

  2. What are the issues with this patient? Are the issues ethical in nature? Are there problems in communication or differences in clinical opinions and treatment protocols? Are there resource allocation issues that may interfere with treatment and care, that is, absence of health insurance? Are there limitations on third-party reimbursements? Are there conflicts among the moral values and ethical principles of the patient, the family, the nurse, the attending physician, and the health care facility?

  3. What is the good to be achieved for this patient? (a) The patient’s biomedical good—the technically good act according to standards of medical and nursing practices identified by clinicians and decided by patient or health care surrogate; (b) the patient’s perception and informed understanding of his or her own good at the time and in the particular circumstances of the clinical issues and impending decisions; (c) the good of the patient as a human person capable of reasoned choices (freedom, dignity, autonomy, and self-determination); (d) the patient’s ultimate good (human flourishing, value and meaning of life, suffering, God, family, and society).

  4. What are the goods and interests of other parties? (a) Family, (b) community, (c) society, (d) the law, (e) policies of health care institutions/clinical settings, and (f) members of the health care team.

  5. How do the issues stand vis-à-vis the issues in comparable cases? (a) Is this case analogous to others? (b) Has some moral consensus been achieved in the analogous cases? (c) Are there ethical and legal precedents? (d) How well does this particular case fit paradigmatic cases in terms of the facts, the issues, and the framing of the issues?

  6. The prudential question—what to decide? In synthesizing the data from these questions and moving toward a proposed intervention two critical questions emerge: (a) What can be done for this patient? (b) What should be done for this patient?

  7. Health science, clinical research, innovative technology, and evidence-based clinical practice continue to evolve at a phenomenal pace. Today, the lives of persons with chronic illnesses can be extended and the quality of life enhanced. Certain forms of cancer once considered fatal now successfully respond to treatment. Treatment of neurological diseases, once causing permanent disability, has given new life to millions. With advanced technology, much can be done to treat specific illness. The question that is paramount in analyzing the needs and resolving ethical dilemmas of the whole person is what should be done for this patient—what is both the technically good and morally right action for this patient. The answer to this question requires a careful review of all of the data accumulated in the course of the clinical analysis. Critical to this analysis is the centrality of the dignity, freedom and autonomy of the human person, and the good that he or she identifies as important as a person with intrinsic dignity and worth.

  8. Evaluation: Once decisions are made and treatments implemented, an assessment of the integrity of the process should be carefully reviewed throughout the clinical experience. This evaluation is a continuous process that requires reconsideration of decisions and interventions as the patient progresses toward healing or toward death.

Read more in CREDO Nursing Leadership (must be on campus or login with COM ID.)

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