Ethical Dilemmas

Miss Shurouq Qadous 27/2/2011

A situation in which an individual feels compelled to make a choice between two or more actions that he or she can reasonably and morally justify, or when evidence or an arguments are inconclusive, is called an ethical dilemma (Beauchamp&Childress,2001;McConnell,2002). One action must be chosen because performing both actions would be impossible.

Dilemmas may arise from conflicts between midwives and other health care professionals, health care organizational administrators, or patients and family members.

Ethical Dilemmas are usually described in terms of right or wrong, duty or obligation, rights or responsibilities, and good or bad. Ethical dilemmas are commonly identified by the question, What should be done?

Nurses / midwives confound ethical dilemmas with tragic circumstances. A tragic circumstance is one when nothing can be done to alleviate the situation. In this case a good choice or solution may be lacking . The sadness of the situation may make the nurse / midwife wish that there was something that could be done, but there are often no further options for treatment.

For example, several years ago a 10 year old boy with leukemia was being considered for a bone marrow transplant. Just as a donor was found , he developed an infection that would not respond to the most potent antibiotics, and donation was no longer a possibility. He died within a few days.

Types of dilemmas
Most moral dilemmas in nursing / midwifery can be identified according to the following classifications: Dilemmas of Beneficence-dilemma that involve deciding what is good as opposed to what its harmful. Dilemmas of autonomy- those that involve deciding what course of action maximize the patient's right of self determination. Dilemmas of justice- dilemmas that involve dividing limited health care resources fairly

 Dilemmas of fidelity- those that are involve honoring promises Dilemmas of nonmaleficence- dilemmas that involve the avoidance of harm Dilemmas of confidentiality- those that involve respecting privileged information Dilemmas of veracity- dilemmas that involve telling or concealing the truth

Origins of Ethical Problems in midwifery

Growing awareness of ethical problems has occurred largely because of (a) social and technological changes and (b) midwifes conflicting loyalties and obligations.

Social and Technological Changes

Social changes, such as the womens movement. The large number of people without health insurance, the high cost of health care. Technology creates new issues that did not exist in earlier times. Before monitors, respirators, and parenteral feedings, there was no question about whether to allow an 800- gram premature infant to die.

Before organ transplantation , death did not require a legal definition that might still permit viable tissues to be removed and given to other living persons. A advances in the ability to decode and control the growth of tissues through gene manipulation present new potential ethical dilemmas related to cloning organisms and altering the course of hereditary disease and biological characteristics. Today, with treatment that can prolong and enhance biologic life, these questions arise: should we do what we know we can?

Conflicting loyalties and obligations

Midwifes experience conflicts among their loyalties and obligations to clients, families, primary care providers, employing institutions. Client needs may conflict with institutional policies, primary care provider preferences, needs of the clients family, or even laws of the state. However, it is not always easy to determine which action best serves the clients needs.

For instance, the nurse may be aware that marijuana has been shown to be effective for a condition a client has that has not responded to mainstream therapies. Although legal issues are involved, the nurse must determine if, ethically, the client should be made aware of a potentially effective alternative. Another example employee strikes.

Making Ethical Decisions

Responsible ethical reasoning is rational and systematic. It should be based on ethical principles and codes rather than on emotions, intuition, fixed policies, or precedent ( )(that is, an earlier similar occurrence).

Two decision making models 1- Thompson and Thompson (1985)

 Review the situation to determine health problems, decision needs, ethical components, and key individuals.  Gather additional information to clarify the situation  Identify the ethical issues in the situation.  Define personal and professional moral positions.  Identify moral positions of key individuals involved  Identify value conflicts, if any  Determine who should make the decision  Identify range of actions with anticipated outcomes.  Decide on a course of action and carry it out.  Evaluate / review results of decision / action.

2- Cassells and Redman (1989)

Identify the moral aspects of nursing care Gather relevant facts related to a moral issue. Clarify and apply personal values Understand ethical theories and principles Utilize competent interdisciplinary resources Propose alternative actions. Apply codes of ethics to help guide actions Choose and implement resolutive action. Participate actively in resolving the issue Apply state and federal laws governing nursing practice.  Evaluate the resolutive action taken          

A good decision is one that is in the clients best interest and at the same time preserves the integrity of all involved. Midwives have ethical obligations to their clients, to the agency that employs them, and to primary care providers. Therefore, midwives must weigh competing factors when making ethical decisions.

Examples of obligations in ethical decisions  Maximize the clients well being  Balance the clients need for autonomy with family members responsibilities for the clients well being  Support each family member and enhance the family support system.  Carry out hospital policies.  Protect other clients well being  Protect the standards of care.

The midwife may feel torn between obligations to the client, the family, and the employer. What is in the clients best interest may be contrary to the midwife personal belief system. In settings in which ethical issues arise frequently, nurses, midwives should establish support systems such as team conferences and use of counseling professionals to allow expression of their feelings.

Types of decisions
Active decisions-ethical decisions and moral
judgments that lead directly to actions and bring about changes Passive decisions- decisions that deny , delay, or avoid action and maintain the status quo by denying or shifting responsibility to avoid changes

 Programmed decisions- decisions that use precedents, established guidelines, procedures, and rules to resolve anticipated, routine, expected types of moral dilemmas Non-programmed decisions- decisions that require a unique response to complex and unexpected moral dilemmas.

Process for resolving ethical problems: recognition of ethical dilemma Gathering relevant factual information Clarify the personal context of the ethical dilemma Identify and clarify the ethical concept Construct and evaluate arguments for each issue. Take action. (Make decision)

Ethical decision making is a skill that can be learned, based on understanding of underlying ethical principles, ethical theories or systems, a decision making model, and the ICM of Ethics.

Apllication of a Bioethical Decision Making Model Mrs. L, a 67- year old women, is hospitalized with multiple fractures and lacerations caused by an automobile accident. Her husband, who was killed in the accident, was taken to the same hospital. Mrs.L,who had been driving the automobile, constantly questions her primary nurse about her husband. The surgeon has told the nurse not to tell Mrs.L about the death of her husband, however, the surgeon does not give the nurse any reason for these instructions. The nurse expresses concern to the charge nurse, who says the surgeons orders must be followed that the surgeon will decide when Mrs.L should be told. However, the nurse is not comfortable with this and wonders what should be done.

Thanks