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Moral philosophy

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A logical framework for making moral/ethical decisions. Provides foundations for ethical theories. Roots of the tree analogy used to make ethical decisions. Naturalism and rationalism are moral philosophies.

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Ethics

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The practical application of morality. Personal consciousness of the moral importance that guides your actions. Ethical theories represent trunk and branches of tree analogy.

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Naturalism

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Moral judgment depends on human nature and is innate. Preprogrammed belief, based on feelings, emotions and human nature. Example: All societies consider murder wrong

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What is the basis for moral reasoning, according to naturalism?

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Sympathy - the sharing (in imagination) of others' feelings.

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Rationalism

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Moral judgment learned through the process of reasoning as we grow up. These ethics learned are truths that come from a higher source and are superior to information we can receive from our senses. Example: Grass may not actually be green, may be perceived different to others or an entirely different color; but moral truths are always true because they come from a higher source - like it's always good to help those in need.

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Utilitarianism

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An ethical theory that holds that an action can be considered good or bad in relation to its end result. *The end justifies the means.* [[What many healthcare decisions are based on]] Example: Triage, critical care beds shortage. State budget cuts funding for HIV rather than immunizations. /Sacrifices autonomy of one for the good of many/ *Spirit* of the law.

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Act-utilitarianism

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Actions chosen to increase the overall good. Example: Stealing after natural disaster to feed family.

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Rule-utilitarianism

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Rules chosen to increase the overall good. Example: Triage, organ transplant allocation, ICU beds

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Deontology

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AKA Kantianism, named after German philosopher Kant. _Basis in rationalism_ An action is judged as good or bad in relation to the act, rather than to its consequences. *The end does not justify the means OR means to an end* Actions based on moral rules and are absolute, regardless of situation. [[Most healthcare ethical codes, including ANA Code of Ethics, are based on this]] Very rigid, stresses the *letter* of the law. /Recognizes dignity and autonomy of all individuals/ Example: Healthcare for all

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Categorical imperative

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No action can be judged as right if it cannot reasonably become a strict law. Example: Stealing food for your hungry family after a natural disaster is justified to you, but this could never become a universal law - we'd be living in an unsafe society.

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Practical imperative

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Treat yourself or others always as an end and never as a means to an end. Example: Sugar daddy is a means to a end, having a second kid to give her kidney to your other sick kid. /Big example:/ Terry Shivo withdrawal of nutrition.

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Focal virtues for cultivating morality

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1) Compassion - active regard for another welfare 2) Discernment - having wisdom and insight by being available and present 3) Trustworthiness - main component of caring 4) Integrity - consistent adherence to morality, cardinal virtue

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Moral particularism

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Uses generalizations of utilitarianism and deontology principles, allows for exceptions, considers unique cases

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Cornerstone of ethical principles?

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Respect for persons - erryone deserves luvin'

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Autonomy

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The freedom to make independent choices regarding care. Self governance. Right to self determination.

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What are the 4 basic elements required for one to be fully autonomous?

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1) Be respected yo 2) They gotta have the ability to determine and formulate goals 3) And have the ability to decide on a plan of action and understand the plan 4) Freedom to act upon their choices

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Do the 4 basic elements of autonomy always have to be met?

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Nah - varying levels of autonomy exists. Example: Groups who can't formulate goals/plan of action: kids, mentally impaired, chemically impaired People who can't actually carry out action plan: prisoners, uninsured, poverty, elderly dude who can't physically live at home anymore

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What are some common ways nurses violate patient autonomy? Gimme 4 good ones.

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1) Projecting our own values on pt. /"I know you're agnostic and don't want a chaplain but Ima call him anyway"/ 2) Failure to recognize differences with cultures/values. /Some cultures lack respect for women, kids - it's their norm/ 3) Assuming pts have more knowledge than they do - this is a biggie. /Pt refuses an MRI or lab work or treatment; we're baffled by this and label them noncompliant when they really don't know wtf is happening/ 4) Focusing on tasks instead of the pt

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What are the *components* of autonomy? 4 of them.

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Informed consent Paternalism Advocacy Compliance

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What's the nurse's responsibility in informed consent?

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Attesting that pt is voluntarily consenting and his rights are respected. MD provides info.

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Paternalism

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Making decisions on behalf of pt without their full consent or knowledge. Before informed consent, doctors used this a lot. "I know what's best for my pt" Avoid this - act in the best interest of the pt and their wants.

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Advocacy

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Supporting, speaking for, defending pt. Seeking goals pt wants. Thin line between this and paternalism especially with incompetent pts.

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Compliance

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Willingness of pt to participate in care. Noncompliance can represent failure of nurse (assuming they know more than they do) or pt (doesn't want to quit smoking) Always give the same care to all pts, no matter if they're compliant or not.

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Confidentiality

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Nondisclosure of private pt info. [[This ethical principle has some of the biggest legal implications b/c of HIPPA]] Pt has right to control personal info and protect privacy. Revealing info could have potential to harm pt (embarassment, ridicule). Also an issue of utility - if pt suspects HCP is revealing private info they may be reluctant to seek care for detrimental things (addiction, mental illness)

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Harm and vulnerability principle

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Confidentiality not honored because the obligation to protect an innocent third party supersedes the obligation to maintain confidentiality. Duty to warn. Notify law enforcement, let law enforcement contact third party. Example: Guy tells his psychiatrist he's going to murder his gf, psych needs to notify police. Or guy has AIDS and still has sex with his wife and doesn't plan to tell her. TB and other communicable diseases that should be reported to TX Health Dptmt

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17 y/o comes in to get birth control rx. Admits step father is abusing her, but she doesn't want to report it. What do you do?

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Under TX Family Code it is not a breach of confidentiality to report child abuse _under age of 17_ For this girl, SHE would have to report it herself for it to be a crime. You can't report it if she doesn't want to. You can give her resources - crisis center, hotline, safety plan

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Beneficence

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To do good, promote well being of the pt. To prevent harm, advocate for the pt. /Carrying out orders, questioning orders/ To remove harm, communicate and report concerns. /Fall risk implementations, whistleblowing when necessary/

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Nonmaleficence

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To do no harm, to do good with the least amount of harm. Must weight the harm against the benefit. /Examples: Painful interventions (burns), broken ribs with CPR, giving a kid an immunization/

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Veracity

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Closely r/t informed consent - telling the truth. Joint Commission now requires full disclosure of medical errors. /Big difference in this ethic with doctors vs nurses. Lots of MD ethical codes say *deception* (nondisclosure of information) is okay to avoid anguish and promote beneficence, but *lying* (purposeful untruths) is not okay. But many other theorists classify this as paternalism. Nursing, on the other hand, just says upholding veracity is principle for autonomy, doesn't get specific./

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A woman got in a car wreck with her 4 children. One of the kids has died, and she doesn't know yet. She is about to go into surgery. What do you do if she asks about her kids?

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Avoid telling her as much as possible. Say something like "I'll find out and let you know when you're out of surgery." If she doesn't ask in the first place, avoid all together. This is *deception* You can't straight up lie to her tho. /Note - book and lecture differ here. Book says if she asks, you have to tell the truth./

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Justice

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Fair, equitable tx without discrimination or bias. *Recognizing that giving to some will deny receipt to others who might've otherwise received*

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Distributive justice

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The allocation of finite healthcare goods and services. Giving to some will deny to others. Burden of going without needs to be shared. /Ex: organ allocation/

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Social justice

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Improving health of the undeserved, vulnerable members of society /Dedicating personal time to health of vulnerable, community work to homeless/

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Fidelity

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Being faithful, keeping promises, fulfilling duty. [[Cornerstone to nurse pt relationship]] *Foundation of our accountability - duty to follow standards of license like NPA and Code of Ethics - Nightingale promise*

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Why is value clarification important?

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Becoming more conscious of what we believe in. Guides clear and thoughtful behavior, promotes effective communication and care, solidifies your personal and professional choices. Belief ➜ Values ➜ Behavior

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Overt values

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Values explicitly communicated through philosophy and policy statements of institutions.

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Covert values

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Implicit, identified through participation in the institution. May be negative

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Moral uncertainty

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Doubt ➜ Inquiry ➜ Belief ➜ Values ➜ Behavior/Truth Enhance self awareness with journaling and stuff

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Moral distress

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Professional and personal values conflict, restrained from pursuing right course of action.

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Moral development

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Basically the holistic approach of growing up and learning what you value is right and wrong in your head (intellectual - cognitive) and in your heart (emotional - affective) and then acting (kinesthetic) on your values

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Piaget's Cognitive Development Stages - Birth -15

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Sensoroimotor Preoperational Concrete operations Formal operation Piaget believes there are no more cognitive ability changes after 15

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Kohlberg's Moral Development

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Ethic of Justice Level 1) Preconventional Level 2) Conventional Level 3) Post Conventional, Principled

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Gilligan's Psychological Development of Women

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Ethic of Caring Concern for survival Responding to needs of others Imperative of care

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Fowler's Faith Development

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6 stages of finding meaning in life Intuitive-projective Mythic-literal Synthetic-conventional Individuative-reflective Conjunctive Universalizing

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AACN's Professional Values (5 total)

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Altruism Autonomy Human dignity Integrity Social justice

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Altruism

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Concern for welfare of others.

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Integrity

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Acting in accordance with code of ethics and standards of practice, honest ethical care

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List the distributive justice theories (4)

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Utilitarian Libertarian Communitarian Egalitarian

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Utilitarian Theory

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Greatest good for the greatest number. Places social goods before individual rights. May deny sickest and vulnerable populations. Distribution based on _cost/benefit ratio_

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Libertarian Theory

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Protecting rights of rights and property of each person, allowing each person to improve his/her circumstances by their own effort. *Views healthcare as a commodity, not a right*

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Communitarian Theory

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Community at center - goal is to enhance the community health and reduce risk factors. Supports commitment of equal access to health care. *If communal funds present, service must be equally available* Food banks, community clinics, day care - encourages community cooperation outside government.

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Egalitarian Theory

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Equal distribution of benefits and burdens. Equal access to basic healthcare. *"Veil of ignorance"* - resources distributed w/o considering social status, assets, etc *Prioritizes supporting vulnerable populations over the greater good*

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Problem vs Dilemma

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Problem - gap between current state and desired state, no moral focus Dilemma - choice between 2 favorable/unfavorable mutually exclusive options

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Ethical Dilemma

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[[Must include conflict between TWO ethical principles]] Obeying 1 ethical principle violates another

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Pt with terminal disease stated he didn't want ventilator or feeding tube. He is now not competent and family wants aggressive tx. Competing moral claims? Conflicting ethical principles?

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Moral claims: I believe in preserving life I believe in preventing suffering OR I believe in respecting one's right to make decisions I believe in preventing suffering OR I believe in doing good and preserving life I believe in honoring pts wishes Ethical Principles: Beneficence vs Nonmaleficence OR Autonomy vs Nonmaleficence OR Beneficence vs fidelity

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Practical Dilemma

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*Moral claims compete with claims of self interest* [[Moral claim has greater weight over self interest]] Ex: Pt coded in ICU, you don't wanna be late to your party, too bad go to the code

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Moral outrage

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Act committed that nurse believes is immoral. Nurse doesn't participate in act but is powerless to prevent. Ex: 9/11

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Moral Reckoning - Nathaniel's Model

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Stage of Ease - new nurse learning her stuff, then boom strike of lightening *situational bind or critical incident* a morally troubling event that challenges values and causes moral distress Stage of Resolution - Take a stand: can involve professional risk; Give up - quitting/leaving situation to protect self and job; Giving in short term - to prepare to make a stand, getting advice and facts Stage of Reflection - reflecting on event, living with consequences

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Conscientious objection

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Right of refusal, freedom of conscious TX NPA protects this right ANA Code 5.4 - preservation of integrity Make objections known at time of employment and at objecting. /Never abandon pt/

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Ethical decision making model - 6 steps

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1. Articulate the problem and desired goal 2. Examine the ethical dilemma, ask questions 3. Define the conflicting ethical principles 4. Comprehend possible alternatives to resolution - get lots of facts, stats, laws 5. Implement resolution to the dilemma 6. Evaluate

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Fee-for-service

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Payment model *Prior to 1980* Focuses on the individual pt, promotes tx that offers benefit, [[assumed unlimited resources.]] Providers charged what market allowed, pts paid thru insurance or self pay. /Resulted in overutilization, big costs and many without access/

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Managed care model

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Payment and delivery model *1980s government payment based on DRGs* DRG - diagnosis related group, grouped disease in body part and government paid categorically Set payments based on diagnosis; attempted to lower costs by dec services, etc *Loss of autonomy for pt and provider* /Hospitals tried to cut costs, malpractice lawsuits increased which birthed _defensive medicine_ - overprotecting from lawsuits. This l/t inc standards of care ➜ inc expectation ➜ rapid tech advancement ➜ profit making became primary motive./ Still assumes unlimited resources. Ignores social responsibility and distributive justice. Lots of potential ethical abuse.

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Futile care

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Overutilization of a few. Managed care model led to this and dec in basic care (rationing on basis of financial means)

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Affordable Care Act

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2010 Pay for Performance Payment and delivery model that ties payments to outcomes, quality, costs *Near universal coverage thru shared responsibility among government, individuals, employers*

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