Ethical dilemmas are more frequent in health care, primarily because of the remarkable advances in medicine and technology. Health practitioners are now able to diagnose and treat illnesses that were lethal a decade ago. The growing understanding of human genetics has also created new and unique dilemmas. Concerns about patient choice, quality of life, and access to health care are also becoming more frequent and complex. As a result, health care professionals face an increasing number of issues for ethical decision-making.
Some research suggests that nurses do not always have a clear understanding of their role in ethical concerns. They may not know how ethical decisions are made and may feel powerless when faced with ethical dilemmas (Zink, & Titus 1996). Decision makers of healthcare practices find themselves in ethical dilemmas when they must choose between courses of action that are based on different moral frameworks, varying organizational philosophies, or conflicting duties or moral principles (Darr, 1997). Although in some cases reasonable people can be strongly committed to different courses of action, in most ethical dilemmas the various players can reach consensus despite cultural or religious differences (Darr, 1997). Decisions of this nature are most times painful and much contemplation is required. Differing ethical theories do not necessarily conflict, and people following diverse philosophies may reach the same conclusions via different reasoning (Darr, 1997). People have opinions and these opinions are what give people a way to express themselves. If people did not have differences of opinions about particular situation, there would be no ethical dilemma (Ecker, 1996). More and more people have recognized the importance of bioethics in health care settings. Ethics committees are an important resource for patients and providers in all healthcare settings, including home health, long-term care, psychiatric facilities, clinics, and hospitals (Beauchamp & Childress, 1994). Ethics committees focus on education, policy development, and clinical consultation on ethical issues. They review decisions and develop policies and procedures about important issues such as informed consent and limitation of treatment.
Nurses and Decisions about Ethical Dilemmas
Ethical decisions are inherent in the daily practice of nurses and other healthcare practitioners and are critical to the care being delivered to patients. Several notable studies have been conducted in recent years about nurses and ethical practice. For example, a study done by the American Nurses Association found that 79 percent of those responding said they faced ethical issues daily or weekly (Zink, & Titus, 1997). A high percentage of nurses said they faced ethical dilemmas “frequently.” Other studies document areas in which nursing needs to strengthen its role in ethical practice. One study revealed that nurses have a relatively low level of ethical sensitivity to issues other than patient autonomy. The study found that approximately twenty-five (25 %) percent of a sample of nurses failed to define or defined incorrectly the term ethical dilemma. Of those who did define it correctly, only forty (40%) percent used a conceptual definition (Oddi, Cassidy, & Fisher, 1995). Others defined ethical dilemmas in specific terms, such as “death and dying,” rather than describing the conceptual basis of the dilemma, that is, the patient’s autonomy versus medical paternalism (Oddi, Cassidy, & Fisher, 1995). This raises concerns that nurses may lack sensitivity to the ethical aspects of numerous practice situations and often use a narrow conceptualization of ethics (Loewy, 1996). Another study, which assessed ethical decision making in nursing, suggested that nurses are not always aware of their role in ethical aspects of practice. Five (5) of fifty -two (52) nurses contacted, declined to participate in the study, saying that they did not make ethical decisions in nursing practice (American Hospital Association, 1994).
The nurse’s code of ethics was written outlining general behaviors that society could expect from nurses, regardless of their educational background, personal values, or nursing experience (Zink, & Titus, 1997). Nurses, as members of the profession, must be aware that the code of ethics nurses contract with society and nurses are therefore committed to uphold specific ethical behaviors. Although the code of ethics was developed for the entire profession, not all nurses are aware of its requirements. A study of five hundred and fourteen (514) nurses with varying educational backgrounds and practice settings found that fewer than forty (40%) percent were familiar with the code (American Hospital Association, 1994).
Both individual and organizational efforts can enhance the ability of nurses to serve as ethical advocates. Individual nurses can receive assistance and support in dealing with ethical issues in a number of ways. Nurses need knowledge to participate articulately in interdisciplinary discussions of ethics because most ethical conflicts involve the whole health team. Many nursing policies have an ethical component, such as those relating to patient abuse, the nurse’s role in informed consent, the impaired nurse, and care of the HIV-positive patient. Nursing staff development is important in helping nurses become effective ethical advocates. Nursing practice inherently involves ethical issues, so ethics education is particularly important for nurses who have not had formal ethics training. Continuing education programs on ethical principles and ethical decision-making models are critical. Emphasis on the interpersonal and communication aspects of ethical involvement will empower the nurse to participate fully as the patient’s ethical advocate. The nurse also needs support when he or she disagrees with the patient’s decision or cannot support the decisions of other health care professionals or those of his or her employer.
Future ethical dilemmas are certain to involve nurses in a variety of practice settings. Nurses bridge the gap between the needs of individual patients and the health care system. Never have the challenges for nursing been greater. However, the challenges bring great opportunity for nurses to move to the forefront in the advocacy role (Smith, 1996). Nurses can be very valuable advocates for bioethical practiceand as the challenges of making ethical decisions become greater, nurses will be forced to perform their advocacy role. However, the climate of the workplace can create barriers for nurses trying to act ethically. Those who participate in making ethical decisions may be perceived to be in conflict with organizational expectations. For example, managers and co-workers may see a nurse who advocates for patient rights or reports the unethical behavior of another health care professional as lacking loyalty to the institution (Oddi, Cassidy, & Fisher, 1995). The position of nurses in the health care hierarchy may create problems, too, as nurses often have great responsibility but little power in making decisions (Oddi, Cassidy, & Fisher, 1995). Nurses need to be empowered towards making ethical decision. This empowerment should be created by managers and hospital administrators. As a result patients would receive better care and nurses are more satisfied with their jobs when they recognize the ethical nature of their work, determine which ethical decisions are theirs to make, and acknowledge their authority in making ethical decisions in practice (Smith, 1996).
Education about ethical responsibility and decision-making may be a part of the problem why nurses do not confront ethical dilemmas. Some experts think nurses are not committed to ethics as a professional priority, because they are poorly socialized about their ethical responsibilities; their education did not expose them to ethics enough (Oddi, Cassidy, & Fisher, 1995). Others have documented a lack of ethics content in nursing fundamentals texts (Killeen, 1986). Some researchers say nurses would be better able to understand the ethical dimensions of the profession and of nursing practice if as students they had had adequate theoretical and experiential preparation texts (Killeen, 1986).But what if this is not so? What if nurses are just not empowered or are less inclined to act because of bureaucratic institutional policies that may create problems after an ethical decision? Personal characteristics and beliefs about ethical involvement can also impair nurses’ ability to act as ethical advocates. Many nurses have a high need to avoid conflict and will act to maintain rapport at all cost (Oddi, Cassidy, & Fisher, 1995).
To avoid conflict, nurses characterize situations involving actual or potential ethical dilemmas as being matters of differing personal opinions, and withdraw from ethical decision-making. Other nurses follow a physician-advocate model, which promotes the goals or ends of medical research or technology. When nurses follow this model, they may believe that a physician’s orders are always correct and see their sole responsibility as communicating these orders to patients (Oddi, Cassidy, & Fisher, 1995). Hence the need for nurses to be able to think and act independently, yet within the framework and scope of healthcare practice.
Nurses often rely on intuition to resolve ethical conflicts, but this may not be the most effective method, because they may not recognize the ethical dilemma, thus not take appropriate action. They may experience moral distress when they are repeatedly exposed to unresolved conflicts (Oddi, Cassidy, & Fisher, 1995). Moreover, even when they identify an ethical issue, not all nurses have the support needed to correct a questionable situation in which the patient’s welfare may be in jeopardy and nurses may not have access to forums where ethical discussions are encouraged. Nurses may seek to avoid the dilemma rather than confronting it or possibly facing organizational barriers needed for resolution because they do not have the tools to solve ethical dilemmas effectively.