Chapter 3

ETHICS & BIOETHICS - ETHICAL

ISSUES & ETHICAL DILEMMAS

Author
Dr. Rohini. T
 Learning Objectives

• Define ethics and bioethics

• Explain ethical principles

• Identify ethical concerns

• Describe ethical issues and dilemmas in healthcare

 Chapter Outline
• Definition of ethics and Bioethics
• Significance of ethical principles
• Components of ethical principles
• Ethical issues and ethical dilemma
• Common ethical problems
• Concept of interest
• Paternalism
• Deception
• Privacy and confidentiality
• Valid consent and refusal
• Allocation of scarce nursing resources
• Conflicts concerning new technology
• Whistle blowing
• Beginning of life issues
• End of life issues
• Issues related to psychiatric care
 Introduction
• Moral philosophy is the basis of ethics, and philosophy is all about
reasoning.

• The field of applied ethics known as ‘bioethics’ is concerned with ethical

issues pertaining to biology and biological processes. It is the study of, and
response to, these moral and ethical issues from a multidisciplinary
perspective.

• Medical ethics, animal ethics, and environmental ethics are all included in
bioethics
 Significance and components of ethical principles

• Strong nurse-patient and interdisciplinary connections are necessary

for collaboration and high-quality patient care, and these relationships
can be developed by applying the ethical standards in nursing.
• Patients who receive care from nurses who uphold high ethical
standards are often more compliant than those who receive care from
nurses who don't.
• Risks to patient and nurse safety are decreased by ethical nursing
practices.
• Using ethical principles as the foundation of practice assists nurses in
making good judgment calls.
 BENEFICENCE

• Beneficence is defined as generous giving, or the quality of being

generous and doing good

- Cambridge Dictionary

• The generic definition of beneficence is an act of charity, mercy, and

kindness. It implies helping others and evokes a variety of moral
responsibilities.
 Non-maleficence
• Inappropriate to do harm to other people. It has a strong connection to
the adage primum non nocere (first do no harm).

• Intentionally exercising nonmaleficence helps the nurse ensure every

possible effort is made to protect patient safety and improve patient
outcomes.
 JUSTICE

• act of being fair or unbiased. Giving each person what they deserve, or,
in more formal terms, their due, is what is meant by justice.
Consequences of lack of implementing Justice

Not Prioritizing Care

• Justice in clinical practice involves acting fairly and requires nurses to utilize critical
thinking and decision-making skills. The treatment of patients in need of priority care
might be delayed if those skills aren't used to carry out justice. Delays in care can
occasionally have serious effects on both the patient and the nurse.

Patients May Feel Rejected

• In the absence of justice, nurses may show partiality to some patients or populations
over others. Some patients could feel rejected or even abandoned if this happens.
Depending on the circumstances, nurses may be penalized for failing to uphold ethical
standards
 Autonomy

• The ability for patients to make their own decisions is referred to as

autonomy.

• Enabling patients to make their own decisions about which health care
interventions they will or will not receive.
 Ethical issues and ethical dilemmas

Ethical issues

• An ethical issue is considered to be simple because the solution can be

found by merely following a specific rule outlined in the Code of Ethics.

Ethical dilemma

• Ethical dilemma is an opposition between two morally righteous actions.

 Common ethical problems

Conflict of interest
• A conflict of interest arises when what is in a person's best interest is not in the
best interest of another person or organization to which that individual owes
loyalty.
Conflict of interest in Healthcare
• A scenario in which a professional decision involving a main interest (such as
patient care, research, or education) is unduly influenced by a secondary interest
(financial gain, personal prestige, academic promotion etc.)
 Common ethical problems

Paternalism

taking activities or making decisions on behalf of another person with the

goal of helping that person.

Paternalism in Nursing and healthcare

It's common for nurses to believe they know the patients' needs better than
patients do.

Ethical issue related to paternalism

 Common ethical problems

Deception

intentional hiding or distortion of the truth through lying, misleading, or

other means.

Deception in Health care and nursing

The lack of information, withholding of information, selection of the

most relevant details, and choice of what information to disclose and
what information not to disclose are all examples of deception.
 Common ethical problems

Privacy and confidentiality

• Privacy is the term used to describe a person's right to restrict access

by others to certain aspects of their person, such as their thoughts,
personal information, and even information found in their body's
tissues and fluids.

• Confidentiality is the process of protecting an individual’s privacy.

Ethical concerns
 Common ethical problems

Valid consent and refusal

• Informed consent refers to a process that includes information and consent rather
than just signing a form.

• The three components of informed consent are knowledge, competency and will.

• The right of patients to refuse medical treatment must be accepted and respected
by healthcare professionals in accordance with the principle of respect for patient
autonomy.

Ethical concerns
 Common ethical problems
Allocation of scarce nursing resources
• The distribution of resources among competing projects or people is
known as resource allocation.

• Resource allocation is an ethical issue because it most fundamentally

involves questions of justice
Distributive justice
• All people must have an equal chance to acquire limited resources in
an egalitarian society, according to the ethical notion of justice.
 Common ethical problems
Conflicts concerning new technologies
• The increasing accessibility of new technology in healthcare raises
dilemmas, particularly in regards to accountability, liability, security,
trustworthiness, and privacy.

• The main normative concerns arising from data collection, analysis, and AI
application are increasingly at the centre of technology-based ethical
debates.

Solution
 Common ethical problems - Whistle-blowing
Requirements to be satisfied before determining a whistleblower’s concern
(i) The person who brought up the issue is a "worker," or someone who has performed labour under a contract. This comprises staff
members,• agency workers, interns, volunteers, student nurses, and student midwives in addition to those who are officially
employed.
(ii) The person expressing concern must think they are acting in the best interests of the public. This indicates that addressing the
issue will help a multitude of individuals and is not just done for one person's advantage. Hence, personal complaints and
grievances are not typically considered whistleblowing.
(iii) A concern must be raised by someone who thinks it demonstrates past, current, or anticipated future misconduct in one or more
of the following categories:
• that a person has disobeyed a law, is disobeying one, or is likely to do so.
• that a miscarriage of justice has taken place, is taking place, or is likely to take place.
• that any person's health or safety has been, is being, or is likely to be in danger.
• that there has been, is now, or is likely to be environmental harm.
• information demonstrating one or more of these requirements has been, is being, or is likely to be purposefully hidden.

(iv) The person expressing concern must think that it falls under our regulatory jurisdiction.

(v) The individual expressing concern must be confident in the truth of the facts they provide.

(vi) The person expressing the concern must not be breaking the law themselves.
Actions taken by nurse to protect themselves during whistleblowing

Consult your
state nurses
Write out your association or
complaint. legal advice
Keep your before moving
perspective by forward with
Keep a record merely the
of all recording the whistleblower.
Record the conversations facts and
violation. relating to the without
reporting expressing any
incident. personal
judgments.
 Common ethical problems – Beginning of life issues
Abortion
Abortion, or the termination of a pregnancy, is a controversial topic
connected to the question of when does life begin.
 Ethical issues related to abortion
Ethical issues with women Ethical issues with the Ethical issues with respect Ethical issues with respect
Family to fetus to society in general

Health: Unwanted Husband's and in-laws' Right to life: Having an Respecting life: It is the
pregnancy has an effect on choices : As both parents abortion is the same as responsibility of the
one's mental and physical conceive a child, abortion murdering a living creature. government to respect each
well-being. might have choices of both life.
the parents involved.

Rights and freedom: Unless Abortion views vary Motherly care: It is an All-inclusiveness: Abortion
there are extremely depending on whether a unquestionable, unwritten shouldn't develop into a
compelling circumstances, family adheres to bond between two lives that social control tactic to
no woman who willingly conservative or liberal cannot be questioned or prevent the emergence of
decided to become pregnant beliefs. governed by the law. differences or disabilities.
is likely to seek an abortion.
 Ethical issues related to abortion
Ethical issues with women Ethical issues with the Ethical issues with respect Ethical issues with respect
Family to fetus to society in general

Body autonomy: Apart from Better life for already-born

losing reproductive choices, children: Many parents
restrictions on abortion prefer abortion to having
might lead to illegal and additional children in order
unsafe abortions. to be able to provide a better
life for already-born
children.
 Common ethical problems

Substance abuse

Fetal Therapy/Intrauterine treatment of fetal conditions

• Prenatal management of various birth defects or fetal deformities is now possible

thanks to advancements in fetal intervention and fetal surgery procedures,
enhanced anesthetic methodologies, and advanced perinatal care at the limits of
viability

Mandated contraception

• Individuals who think that life begins at conception have an ethical dilemma.
 Ethical concerns related to infertility treatment

• To boost the likelihood of pregnancy, multiple fertilized eggs may be

introduced to the womb during IVF procedures. However, this also raises
Multiple pregnancies
the possibility of having two or more fetuses, which raises the risk of
premature birth, infant health issues, and low birth weight in the newborn.
• When a woman undergoes assisted conception, the clinic she attends may
offer to freeze any additional fertilized eggs that were not implanted, for
Embryos any future attempts at conception. It is important for people to think about
what they would like done with their eggs in the case of their death or a
divorce and to leave written instructions reflecting their preferences.
• A couple may decide to use donated sperm or eggs, or they may decide to
Donor eggs/sperm or employ a surrogate mother to carry their baby. In these situations, couples
surrogacy must talk to the clinic or an attorney about having a contract created that
outlines each party's rights and obligations to the future child and family.
 Common ethical problems – End of life issues
• The process, which begins with the diagnosis of a fatal illness, involves the patient's
desired dignity death as well as the post-death grief period.
• Challenging to make decisions on end-of-life care:
• Cardiopulmonary resuscitation
• Mechanical ventilation, extracorporeal membrane oxygenation, and mechanical
circulatory support
• Artificial nutrition and hydration
• [Link] sedation
• Withholding and withdrawing treatment
• Euthanasia and physician-assisted suicide

Role of Nurse in dealing with end of life issues

 Problems and solutions utilized by Nurses for end of life issues
Problems Solutions

Ineffective communication Nurses may experience a breakdown in communication throughout the decision-
making process, whether it be because a patient can no longer speak for
themselves or because family members find it difficult to express what their
loved one wants. Conversations about death and dying are never easy, but they
must take place. A clean line of communication is ensured by asking patients
early about their preferences and giving them accurate information and tools.

Compromised patient's autonomy The Patient Self-Determination Act (PSDA) attempts to improve communication
between patients and healthcare professionals. It's crucial as a nurse to respect
patient autonomy while considering the best course of action without
undermining the patient's choice. In order to ensure that patients' desires are
upheld in the event that they are unable to make decisions about their own care,
nurses should urge patients and their significant others to talk about end-of-life
care and to implement advance directives.
 Problems and solutions utilized by Nurses for end of life issues
Problems Solutions

Ineffective management of Nursing care for patients towards the end of their lives sometimes involves
symptoms treating symptoms, which raises the issue of whether the advantages of utilizing
medicine exceed any potential risks and side effects. The possibility of drug
adverse effects must be weighed against the need to alleviate symptoms. The
key to success is to always maintain a sense of balance and to keep your attention
on what will improve the patient's quality of life.

Shared decision-making Nurses must decide whether to accept the patient's desires or assume the best
intentions of significant others when they try to go against the patient's wishes. A
living will, medical power of attorney, physician instructions for life-sustaining
treatment, and DNR orders are examples of advance directives that should be
thought about beforehand and presented throughout the decision-making process.
Patients and significant others should be ready for circumstances that might have
otherwise seemed beyond their control.
 Types of Euthanasia
Active euthanasia Killing a patient by active means, such as administering a deadly amount of medication. Occasionally known as
"aggressive" euthanasia.

Passive euthanasia The deliberate withholding of artificial life support, such as a ventilator or feeding tube, is known as passive
euthanasia. There is a difference between withholding life support and withdrawing it (removal of the patient off
life support), according to certain ethicists.
Voluntary euthanasia With the patient's permission.

Involuntary euthanasia Without the patient's consent, such as when the patient is asleep and it is unclear what he or she wants to happen.
Some ethicists make a distinction between forms that are "involuntary" (against the patient's wants) and
"nonvoluntary" (done without the patient's consent but with no knowledge of their wishes).
Self-administered The patient administers the means of death.
euthanasia

Other-administered The means of death are administered by someone other than the patient.
euthanasia

Assisted The patient administers the means of death, but with the help of a medical professional.

Mercy killing The term "mercy-killing" typically refers to active, involuntary or non-voluntary euthanasia that is delivered by a
third party. To put it another way, someone intentionally kills a patient to put an end to their misery. Some ethicists
believe
Physician-assisted suicide Refers to active, voluntary assisted euthanasia in which a doctor provides the patient with assistance. A physician
provides the patient with a means, such as sufficient medication, for the patient to kill him or herself.
 Ethical dilemma
• Do not attempt resuscitation (DNAR)
• If a patient has a DNR or DNAR order, it signifies that the patient has chosen
to avoid initiating or receiving cardiopulmonary resuscitation (CPR) in the
case of a cardiac arrest.
 Issues related to psychiatric care
• Non-compliance
The term ‘non-compliant patient’ generally refers to a patient who
intentionally refuses to take a prescribed medication or does not follow
the doctor’s treatment recommendations.
 Managing non-compliant patients
Traits needed by nurse Description
Be compassionate Make every effort to be empathetic, in order to recognize the difficulties, they could encounter when
attempting to comprehend your wishes.
Educate Take charge and ask them to repeat what you've said back to them, or take the time to explain your
instructions in terms they can understand.
Record everything It's crucial to keep exact records while working with people who don't comply. We'll have a verifiable
record to consult in the event of non-compliance by documenting what is talked with the patient, all
diagnoses and treatment plans, and any queries or worries the patient — or their visiting friends and
family — may have.

Establish boundaries and If you set boundaries and firmly enforce them, you will eventually assist the patient in thinking
stick to them through the actual consequences of their noncompliance. Always be prepared to uphold the
boundaries you set since doing otherwise is detrimental to both you as a healthcare provider and them
as a patient.
Avoid ultimatums Instead of issuing meaningless threats to a non-compliant patient, remain realistic when outlining
their options. Stay focused on the positive outcomes of being compliant which may help you gain
well-earned credibility and trust. Actively avoid a power struggle, explain the potential scenarios and
consequences, but always give the patient their rightful choice.
 Restraints and seclusion
• Seclusion is the act of confining a patient in a vacant room with a closed door
in order to contain an emergency situation.
• Physical restraints, on the other hand, limit patient movement.
Ethical concerns
• violates on the patient's autonomy and right to refuse treatment.
• Patients frequently perceive these procedures as a sort of punishment rather
than treatment
Nursing considerations for seclusion and restraints
 Refusal to take food
• Commonly, hospitalized individuals with mental illnesses refuse food,
which can lead to cachexia and, if ignored, death

Consequences and nursing considerations

• increase psychotic symptoms

• malnutrition-related seizures

• death rate is generally higher in patients

Summary
Thank you