Choosing a Leadership Style (Marquis & Huston, 2012)
DISPLAY 4.2 Ethical Principles
the right to truth and, in fact, that he has the duty to be truthful.
The intuitionist framework allows the decision maker to review each ethical problem or issue on a case-by- case basis, comparing the relative weights of goals, duties, and rights. This weighting is determined primarily by intuition—what the decision maker believes is right for that particular situation. Recently, some ethical theorists have begun questioning the appropriateness of intuitionism as an ethical decision-making framework because of the potential for subjectivity and bias. All of the cases solved in this chapter involve some degree of decision making by intuition.
Other more recent theories of ethical philosophy include ethical relativism and ethical universalism. Ethical relativism suggests that individuals make decisions based only on what seems right or reasonable according to their value system or culture. Conversely, universalism holds that ethical principles are universal and constant and that ethical decision making should not vary as a result of individual circumstances or cultural
differences.
Principles of Ethical Reasoning
Both teleological and deontological theorists have developed a group of moral principles that are used for ethical reasoning. These principles of ethical reasoning further explore and define what beliefs or values form the basis for decision making. Respect for people is the most basic and universal ethical principle. The major ethical principles stemming from this basic principle are discussed in Display 4.2.
The most fundamental universal principle is respect for people.
Paternalism
This principle is related to beneficence in that one person assumes the authority to make a decision for another. In clinical nursing, care providers may become paternalistic when patients lack some capacity with regard to decision making, and in some cases, even when they do not (Mendes, 2015). Because paternalism limits freedom of choice, most ethical theorists believe that paternalism is justified only to prevent a person from coming to harm.
Unfortunately, paternalism is present in nursing management as well as clinical decision making. For example, some managers use the principle of paternalism in subordinates’ career planning. In doing so, managers assume that they have greater knowledge of what an employee’s short- and long-term goals should be than the employee does.
Utility
This principle reflects a belief in utilitarianism—what is best for the common good outweighs what is best for the individual. Utility justifies paternalism as a means of restricting individual freedom. Managers who use the principle of utility need to be careful not to become so focused on desired group outcomes that they become less humanistic.
Justice (Treating People Fairly)
This principle states that equals should be treated equally and that unequals should be treated according to their differences. This principle is frequently applied when there are scarcities or competition for resources or benefits. The manager who uses the principle of justice will work to see that pay raises reflect consistency in terms of performance and time in service.
Woods (2012) notes that in the last few decades, a growing number of commentators have questioned the appropriateness of the “justice view” of ethics as a suitable approach in health-care ethics and most certainly in nursing. Woods noted that nurses do not readily adopt the high degree of impartiality and objectivity that is associated with a justice view; instead, their moral practices are more accurately reflected through the use of alternative approaches such as relational or care-based ethics. This observation suggests the need for a more ethically refined nursing response to an increasingly complex set of sociocultural inequalities such as a combined social justice and relational care-based approach. Woods maintains that such an approach is not only possible but crucial if nurses are to realize their full potential as ethical agents for individual and social good.
LEARNING EXERCISE
4.1
Are Some More Equal Than Others?
R
esearch suggests that individuals with health insurance in this country have better access to health-care services and enjoy better health-care outcomes than those who do not. This does not mean, however, that all individuals with health insurance receive “equal treatment.” Medicaid recipients (people who arefinancially indigent) often complain that although they have public insurance, many private providers refuse to accept them as patients. Patients enrolled in managed care suggest that their treatment options are more limited than traditional private insurance because of the use of gatekeepers, required authorizations, and queuing. Some individuals, with lower cost insurance plans under the Patient Protection and
Affordable Care Act, suggest that high out-of-pocket costs for copayments and deductibles continue to restrict their choice to access needed care.
A S S I G N M E N T:
Using the ethical principle of justice, determine whether health care in this country should be a right or a privilege. Are the uninsured and the insured “unequals” that should be treated according to their differences? Does the type of health insurance that one has also create a system of
unequals? If so, are the unequals being treated according to their differences?
Veracity (Truth Telling)
This principle is used to explain how people feel about the need for truth telling or the acceptability of deception. A manager who believes that deception is morally acceptable if it is done with the objective of beneficence may tell all rejected job applicants that they were highly considered whether they had been or not.
LEARNING EXERCISE
4.2
Weighing Veracity Versus Nonmaleficence
Y
ou are a second-year nursing student. During the first year of the nursing program, you formed a close friendship with Susan, another nursing student, and the two of you spend many of your free evenings and weekends together doing fun things. The only thing that drives you a bit crazy about your friend is that she is incredibly messy. When you go to her home, you usually see dirty dishes piled in the sink, dog hair over all the furniture, clothing strewn all over the apartment, and uneaten pizza or other half spoiled food sitting on the floor. You attempt to limit your time at her apartment because it is so bothersome to you, so it has not been a factor in your friendship.Today, when Susan and you are sitting at the dining table in your apartment, your current roommate tells you that she is unexpectedly vacating her lease at the end of the month. Susan becomes excited and shares that her lease will end at the end of this month as well and suggests how much fun it would be if the two of you could move in together. She immediately begins talking about when she could move in, where she would locate her furniture in the apartment, and where her dog might stay when the two of you are in clinical. Although you value Susan’s friendship and really enjoy the time you spend together, the idea of living with someone as untidy as Susan is not something you want to do. Unfortunately, your current lease does not preclude pets or subleases.
A S S I G N M E N T:
Decide how you will respond to Susan. Will you tell her the truth? Are your values regarding veracity stronger or weaker than your desire to cause no harm to Susan’s feelings
(nonmaleficence)?
Fidelity (Keeping Promises)
Fidelity refers to the moral obligation that individuals should be faithful to their commitments and promises.
Breaking a promise is believed by many ethicists to be wrong regardless of the consequences. In other words, even if there were no far-reaching negative results of the broken promise, it is still wrong because it would render the making of any promise meaningless. However, there are times when keeping a promise (fidelity) may not be in the best interest of the other party, as discussed under “Confidentiality (Respecting Privileged Information)” section. Although nurses have multiple fidelity duties (patient, physician, organization,
profession, and self) that at times may be in conflict, the American Nurses Association (ANA) Code of Ethics is clear that the nurse’s primary commitment is to the patient (ANA, 2015).
Confidentiality (Respecting Privileged Information)
The obligation to observe the privacy of another and to hold certain information in strict confidence is a basic ethical principle and a foundation of both medical and nursing ethics. However, as in deception, there are times when the presumption against disclosing information must be overridden. For example, health-care managers are required by law to report certain cases, such as drug abuse in employees, elder abuse, and child abuse.
LEARNING EXERCISE
4.3
Family Values
Y
ou are the evening shift charge nurse of the postanesthesia care unit (PACU). You have just admitted a 32-year-old woman who 2 hours ago was thrown from a Jeep in which she was a passenger. She was rushed to the emergency department and subsequently to surgery, where cranial burr holes were completed and an intracranial monitor was placed. No further cranial exploration was attempted because the patient sustained extensive and massive neurologic damage. She will probably not survive your shift. The plan is to hold her in the PACU for 1 hour and, if she is still alive, transfer her to the intensive care unit (ICU).Shortly after receiving the patient, you are approached by the evening house supervisor, who says that the patient’s sister is pleading to be allowed into the PACU. Normally, visitors are not allowed into the PACU when patients are being held there only temporarily, but occasionally exceptions are made. Tonight, the PACU is empty except for this patient. You decide to bend the rules and allow the young woman’s sister to come in. The visiting sister is near collapse; it is obvious that she had been the driver of the Jeep.
As the visitor continues to speak to the comatose patient, her behavior and words make you begin to wonder if she is indeed the sister.
Within 15 minutes, the house supervisor returns and states, “I have made a terrible mistake. The patient’s family just arrived, and they say that the visitor we just allowed into the PACU is not a member of the family but is the patient’s lover. They are very angry and demand that this woman not be allowed to see the patient.”
You approach the visitor and confront her in a kindly manner regarding the information that you have just received. She looks at you with tears streaming down her face and says, “Yes, it is true. Mary and I have been together for 6 years. Her family disowned her because of it, but we were everything to each other. She has been my life, and I have been hers. Please, please let me stay. I will never see her again. I know the family will not allow me to attend the funeral. I need to say my goodbyes. Please let me stay. It is not fair that they have the legal right to be family when I have been the one to love and care for Mary.”
A S S I G N M E N T:
You must decide what to do. Recognize that your own value system will play a part in your decision. List several alternatives that are available to you. Identify which ethical frameworks or principles most affected your decision making.
American Nurses Association Code of Ethics and Professional Standards
Professional ethics relates to the values held by a particular profession. A professional code of ethics then is a set of principles, established by a profession, to guide the individual practitioner. The first Code of Ethics for Nurses was adopted by the ANA in 1950 and has been revised 6 times since then, most recently in 2015. This code outlines the important general values, duties, and responsibilities that flow from the specific role of being a nurse. Although not legally binding, the code functions as a guide to the highest ethical practice standards for nurses and as an aid for moral thinking.
The 2015 ANA Code of Ethics for Nurses has nine statements. The professional issues in the first three statements are concerned with protection of clients’ rights and safety; those in the next three pertain to
promoting healthy work cultures and self-care. The social issues of the last three statements of the code relates to the nurse’s obligations to society and the profession (Display 4.3).
DISPLAY 4.3 American Nurses Association (2015) Code of Ethics for Nurses
1. The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.
2. The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.
3. The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.
4. The nurse has the authority, accountability, and responsibility for nursing practice; makes decisions;
and takes action consistent with the obligation to promote health and to provide optimal care.
5. The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.
6. The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.
7. The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.
8. The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.
9. The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.
Source: American Nurses Association (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Author.
In regard to ethics, Provisions 5 and 6 focus on ethical issues related to boundaries of duty and loyalty.
Lachman, O’Connor Swanson, and Winland-Brown (2015) suggest that the language used in the revised Code makes these provisions more precise and the interpretive statements supporting the provisions better
organized, making them easier to understand. Lachman et al. also note that Provisions 7 through 9 concentrate on the nurse’s ethical duties beyond individual patient encounters and suggest that these provisions had the most significant changes because they focus on the nurse’s obligation to address social justice issues through direct action and involvement in health policy as well as a responsibility to contribute to nursing knowledge through scholarly inquiry and research.
Professional codes of ethics function as a guide to the highest standards of ethical practice for nurses. They are not legally binding.
Another document that may be helpful specifically to the nurse-manager in creating and maintaining an ethical work environment is Nursing Administration: Scope and Standards of Practice published by the ANA.
These standards, revised in 2009, specifically delineate professional standards in management ethics, and these appear in Display 4.4.