Ethics and Ethical Decision-Making

Frameworks
LWS101: Week 2
Dr Malcolm Smith
mk.smith@qut.edu.au

CRICOS No.00213J
Introduction to Ethics

Ethics is not a black-and-white subject, which you either

know or dont know Ethics always involves thinking and
feeling, study and practice, knowledge and intuition. As
such, ethics involves the whole person of you the nurse,
and the whole person of the patient or client. This is a tall
order; it is also a personal challenge.
(Tschudin, V., & Farr, B. (1994). Nursing ethics VI: Particular features. Nursing Standard,
9(4), 51-57).
What is an ethical issue?
Ethics might be experienced as:

1) ethical violations incompetent or deliberate wrong-

doing in care;
2) ethical dilemmas arising from a situation where there
may be opposing, but equally morally legitimate
approaches to resolve a dilemma; or
3) ethical distress moral distress (guilt, concern,
distaste) arising from action or inaction imposed upon a
person by another health professional, organisation or
government.
Purpose of Ethical Standards
The purpose of the Code of Ethics for Nurses in Australia,
(2008) is to:
identify the fundamental ethical standards and values to
which the nursing profession is committed, and that are
incorporated in other endorsed professional nursing
guidelines and standards of conduct
provide nurses with a reference point from which to reflect
on the conduct of themselves and others
guide ethical decision making and practice
indicates to the community the human rights standards
and ethical values it can expect nurses to uphold.
Ethical theories: Consequentialist

Teleological (from the Greek telos: consequences)

theories judge conduct in accordance with its
consequences

Utilitarianism is the most famous of these theories

Jeremy Bentham and John Stuart Mill: hedonists

their approach to ethics founded upon pursuit of
(greatest overall) pleasure
Utilitarianism
How do we measure consequences?
Pleasure/pain? (Bentham)
Happiness? (J S Mill)
Ideals? (G E Moore)

Whose interests and which consequences are relevant?

Just mine? (egoism)
A groups interests? (group utilitarianism)
Everyones? (utilitarianism)

How do we rank the outcomes?

Dependant upon a ranking of values?
Ethical theories: Deontological theory
Deontological theory (from the Greek deontos: duty) is concerned with the
intrinsic rightness or wrongness of an action, not the consequences
Concerned with duty
Ultimate basis: pure reason

Immanuel Kant
The only thing in the world which is good without qualification is a good
will
Kant set out his theory in the categorical imperative
Applies unconditionally (such as keep your promises)

Two formulations of the categorical imperative relevant:

Universal moral law
Treat people as ends
Ethical principles

Beauchamp and Childress (2001) devised four ethical

principles to guide ethical reflection within health care
These principles will be used to organise ethical reflection
within this unit
These principles and/or sub-principles may be in conflict with
each other
T. Beauchamp and J. Childress, Principles of Biomedical Ethics, 6 th ed. (Oxford: Oxford University
Press, 2009).
T. Beauchamp and J. Childress, Principles of Biomedical Ethics, 6th ed. (Oxford: Oxford University
Press, 2009).
Autonomy
The right to choose for yourself what is in your best
interest self-determination

Every human being of adult years and sound mind has a

right to determine what should be done with his own body
Schloendorff v Society of New York Hospital (1914) 211 NY 125 at 126.
Autonomy

Autonomy creates an
ethical obligation for
nurses to respect an
individuals right to make
decisions

J.S. Mill suggests that autonomy should only be limited to

protect others from harm
Cultural influences on how autonomy is viewed
In some cultures, individual autonomy is not prized over
other collective forms of decision-making.

For example, Indigenous Australians may be a need for

family, community or specific community members to be
involved before treatment is considered acceptable.
See P McGrath and E Phillips (2008). Western Notions of Informed Consent
and Indigenous Cultures: Australian Findings at the Interface., Journal of
Bioethical Inquiry 5(1) pp. 21-31. (reading for next week)
Beneficence
The duty to benefit and assist others, to care for their
welfare and to always act in the best interests of the
patient

This duty extends to the need to undertake professional

development and training, to collaborate effectively with
others, to keep good records, and to advocate for
patients

Carried too far beneficence can become paternalism

Non-maleficence
The duty to do no harm and to protect others from harm

A nurse must not needlessly harm or injure a patient,

either through a nurses action or an omission or failure to
act

There is an ethical duty (reinforced by law) to provide a

proper standard of care that avoids or minimises the risk
of harm

This principle affirms the need for professional

competence
Justice
Distributive justice the fair distribution
and allocation of health services

Rights based justice respect

patient rights

Legal justice respect morally just laws and

be accountable for acts or failures to act (omissions)
Ethical Decision-Making Framework
Scenario
Hilda is an elderly woman newly resident in a nursing
home. She has moderate dementia. Her capacity varies
from day to day - some days she is competent to make
decisions, while one other days she is not.

Hilda approaches the manager of the nursing home and

asks not to be attended by the nurse with a strong
European accent (the staff member is German). She
refuses to explain why she has made this request.
Ethical Decision-Making Framework
Working through the problem Step 1
Identify the problem
- Hildas request appears to amount to be discriminatory

Identify involved individuals

- Hilda, Hildas family, staff at the nursing home, her GP

Gather information
- Read the scenario carefully!
- Note that you are given key information in this unit. When
working/on placement, you will have to gather key
information. For this reason, gather relevant facts might not
be a necessary step in your assignment/exam answer.
- Do NOT repeat the facts of the question in your answer.
Scenario contd.
Upon enquiry Hildas family confirm that in WWII, Hilda
was a prisoner of war and subjected to inhumane
treatment.

Hildas GP confirms that Hilda has PTSD as a result of her

experiences

Hildas GP notes that Hilda has flashbacks to that time

Ethical Decision-Making Framework
Step 2: Evaluate
In order to evaluate you must:

a) Consider the ethics

Which value statements from the Code of Ethics are
relevant and why?
Which of the 4 ethical principles (Beneficence, Non-
maleficence, Autonomy and Justice) are most relevant
and why?

b) Consider the law

Which legal principles are relevant and explain why.
Step 2: evaluate (a)
Code of Ethics for Nurses in Australia (2008)

VS 2(2): Nurses actively preserve the dignity of

people through practised kindness and by
recognising the vulnerability and powerlessness of
people in their care... This vulnerability creates a
power differential... between nurses and people in
their care
Hilda is obviously very vulnerable (due to her past
history and current health conditions, and her status
as a resident with limited or no control over what
occurs in the facility). Nurses are in a position of
power.
Step 2 evaluate (a)
Code of Ethics for Nurses in Australia (2008)

VS 3(4) Nurses ... acknowledge the need for non-

discriminatory interpersonal relationships in this
context it is important not to allow other nurses to be
the subject of discrimination.

VS4(6) Nurses valuing non-harmful, non-

discriminatory care provide nursing care appropriate
to the individual that recognises their particular needs
and rights. Hilda could be physically or emotionally
harmed if the particular nurse provides her care
Code of Ethics cont .

VS6(1) Nurses have a moral and legal right to practice in a

safe environment, without fear for their own safety or that of
others ...

The nurse who attempts to provide care to Hilda may place

her or himself and/or colleagues at risk of physical
/emotional/ psychological harm. The safety and/or wellbeing
of other residents and Hilda may also be compromised.
Ethical principles
Autonomy
- In general the rights of patients to make decisions about
what is in their best interests should be respected.

- But there are limits to autonomy if a persons decisions

are likely to harm others.

- Hildas request may harm the nurse by discriminating

against them
Beneficence and non-maleficence

The attendance of this particular nurse may cause Hilda

extreme physical, psychological and emotional distress

- Hildas distress may inadvertently cause physical injury

to staff or other patients, or emotional distress to staff
whose presence may trigger a reaction
Justice

Legal Justice
- As a matter of legal justice to all members of staff
(irrespective of their ethnic or cultural background), the
manager should respect the law that prohibits
discrimination, but are there any exceptions to this law?

Distributive Justice
- Human resources are scarce and there is a question
about whether it is fair to other patients to arrange
staffing around the request of one patient
Evaluate - The Law (b)
- Section 7 of the Anti-Discrimination Act 1991 (QLD) (the
Act) states that it is prohibited to discriminate on the
grounds of race. Hildas request relates to the different
treatment of staff based on that individuals nationality
- Under the Act, race is defined to include: (a) colour; and (b) descent or
ancestry; and (c) ethnicity or ethnic origin; and (d) nationality or
national origin (Schedule, Dictionary)
- Section 10(3) of the Act says that the motive for
discrimination is irrelevant.
- Section 108 of the Act contains an exception when a
form of discrimination is reasonably necessary to
protect the health and safety of people at a place of
work. Is it reasonable & necessary to take action?
Conflicts between and within ethical principles
and law
There is a conflict between ethical and legal principles

Acting in what seems to be the best interests of Hilda by

agreeing to Hildas request would be harmful (through
discrimination) to the staff member

The law is clear that it does not matter if the reason for
discrimination is beneficent as it is still discrimination
unless it can be argued there is a workplace health and
safety issue
Ethical Decision-Making Framework
Step 3 Action
To complete step 3 you must:

a) Consider which conduct statements from the Code of

Professional Conduct are relevant and explain why.

b) Identify some options for action and explain which you

would adopt.
Step 3 Action
Code of Professional Conduct (2008)

CS4(3) ... Nurses take appropriate action when observing

prejudicial and discriminatory attitudes and behaviours,
whether by people receiving treatment and care in
nursing and related areas of health and aged care.

Hilda appears to be discriminating on the basis of

nationality. But she may have made the request to protect
herself and affected staff from physical, psychological and
emotional harm due to a reaction she cannot control.
Action
CS3(1) nurses are familiar with relevant laws and
ensure they do not engage in clinical or other
practices prohibited by such laws nurses should
be familiar with anti-discrimination law.

CS8(2) Nurses take reasonable measures to

establish a sense of trust in people receiving care that
their ... well-being will be protected when receiving
care Hildas wellbeing may be affected when
receiving care from this particular nurse is it
reasonable/practicable that they not provide care?
What are your options?

Option 1: Refusing Hildas request - may cause serious

physical, psychological and emotional harm to Hilda and to
the staff member

Option 2: Agreeing to Hildas request may constitute direct

discrimination against the nurse
Action

A decision must be made;

The decision must be justified;

The nursing manager must take responsibility for the

decision
Action
Seek urgent expert advice from (potentially):
- a geriatrician who specialises in dementia
- a lawyer about the Act and the impact of other law e.g.
occupational safety and health, etc.
- other nursing managers, the state Department of Health,
Commonwealth bodies etc.

Consider talking to relevant staff about the situation

Ethical Decision-Making Framework
Step 4 - Implementation
A plan must be developed to implement the decision and to
address any foreseeable consequences of the decision
The decision and its rationale must be communicated to
Hilda (and her family).
Communicate with relevant staff and their union
representative.
Document the decision and its
justification.
Develop a care plan for Hilda.
Run education sessions for staff.
Ethical Decision-Making Framework
Step 5 Evaluation and Reflection

The decision-making process should be evaluated

Seek support when required
Skill-up if necessary
Ethical Decision-Making Framework
Read the
Question!

Discuss relevant
Code of Ethics VS
Discuss relevant
Discuss relevant
Legal Principles
Ethical Principles

Discuss relevant
Code of Conduct
CS
Next week

Introduction to Australian Legal Systems

For next weeks tutorial required reading - McGrath, Pam

and Phillips, Emma (2008).
Western notions of informed consent and Indigenous Cultures :
Australian findings at the interface
., Bioethical Inquiry 5 (1) pp.21-31 (available on CMD).
QUESTIONS?