Ethics, Values and Decision-Making in Nursing Practice RIGHT FROM WRONG

A nurse's primary tasks are monitoring the patient's vital signs, administering medications, and helping doctors treat and perform procedures (Williams, 2012). Oftentimes and in many cases, these technical skills must be guided by certain and pertinent moral and ethical principles. This ethical and moral component of her overall responsibility is so important and critical that a code of ethics was created by the American Nurses Association to guide her in inevitable ethical dilemmas (Williams). These ethical dilemmas can include the clash between the principle of confidentiality and the concept of reasonable limits, between two or more ethical principles involving confidentiality, and the influence of culture on values.

B. Importance of Ethical Theory to Nursing

In 1991, the Joint Commission on Accreditation of Healthcare Organizations or JCAHO expressed the mandate that institutions shall address ethical issues in patient care and requires all health professionals to be educated about ethics (NYSNA, 2004). In a 2004 National Ethics Teleconference, JCAHO stressed that these healthcare institutions must "respect the culture and rights of patients" by respecting patient autonomy and shared decision-making. It recommended their involvement in issues, including informed consent, Do Not Resuscitate orders, assessment and management of pain, privacy and confidentiality, and organ and tissue procurement and donation. Nurses may use a systematic approach in processing an ethical issue and decision-making in their practice. It consists of assessing and identifying the ethical issue, developing a plan based on ethical principles, and choosing a process for its implementation and evaluation (NYSNA).

An example of an ethical dilemma is unsafe patient-to-nurse ratio (Oguejiofo, 2012). The nurse has the ethical duty to care for and keep the patient safe. She confronts an ethical dilemma when there are too many patients to adequately care for at the same time (Oguejiofo).

C. The Principle of Confidentiality vs. The Concept of Reasonable Limits

The Elements of the Principle of Confidentiality

Confidentiality is a time-honored recognized patient's right (Kotak & Lawson, 2008). It is also fundamental and central to the trust relationship between the doctor and his patient. It emanates from the law of confidentiality, the Human Rights Act, General Medical Council guidelines, healthcare contracts and ethical standards. It is part of a patient's autonomy, which is one of the ethical principles of the doctor-patient confidential relationship. Autonomy refers to self-rule, which extends to control over information about oneself. Breaking confidentiality also affects the other ethical principles: the principle of beneficence for not doing good; non-maleficience for doing harm; and an injustice. Confidentiality must be kept in order to preserve the doctor-patient relationship, avoid litigation and to protect the doctor-public relationship. The doctor-patient relationship is essential for the patient both ethically and in for practical purposes. Breaking confidentiality affects both adversely (Kotak & Lawson).

The Elements of the Concept of Reasonable Limits

Respect for individual or patient autonomy is, however, not absolute (Slowther, 2006). It is limited by a higher duty to protect the patient himself or the interests of other persons or society. Applying the utilitarian approach of balancing benefits and harms can tilt the favor from confidentiality but with strict guidance on when and how confidentiality may be breached. Breaking confidentiality may be the preferred choice if keeping it will be redound to the patient's harm, to that of another person or to the public interest (Slowther).

Rationale for Breaking Confidentiality

Advances in the electronic acquisition, storage and dispatch of patient information are excellent opportunities for improving care itself (Slowther, 2008). At the same time, patient data can be tapped and used as basis for public health strategies, contributions to research and the more efficient use of precious healthcare resources (Badzek et al., 2012). The promise of genetic testing is another justification as the test result of a member should be revealed for the benefit or survival of the rest of the family (Slowther).

Justify Keeping or Breaking...

Experience, however, shows that not all patients understand or agree to this. If the information is revealed against the patient's wishes, she is likely to lose trust in her doctor, stop revealing other important information and thus imperil her own health. If people learn that many healthcare professionals breach confidentiality, they may not cooperate and withhold health information, which is badly needed for research and treatment. Moreover, few will want to consult with these professionals or even bring lawsuits against them (Slowther).
D. Resolving Conflict between Ethical Principles

(1) Individual autonomy is violated if confidentiality is breached in the given case (Yale University, 2006). As already described, the doctor has the duty to maintain patient confidentiality as set forth by professional codes of conduct. The patient holds the right to all information about his circumstances and how he wants them used. Sharing them without his express consent constitutes lack of respect for his personal autonomy. It also violates the ethical principle of justice in that the revelation is unjust to the patient whose confidence and autonomy are violated. (2) The utilitarian approach balances the benefits against the harms produced by a given act. Revealing new breast cancer results to another or other family members poses only limited disadvantage to the patient but benefits a great deal family members who may have inherited the predisposition. The right to beneficence is not limited to the patient but extends to family members and to society. Confidentiality may thus be broken (Yale University).

E. The Influence of Culture on Values

American culture emphasizes self-reliance and individualism and value individual rights more that that of the family or society (Ludwick & Silva, 2000). But about 70% of surrounding cultures are collectivistic or group-conscious rather than individualistic. Many cultures make health decisions through groups, such as family, community and/or society. The ethical principle of autonomy relates to the individual right to make his own decisions. It also respects the autonomy of others. Hence, the nurse should see that the lack of respect for the decision-making of ethnic peoples is unethical. The ethical principle of justice clashes with profiting in a free market and "to each person based on need." In America's free-market environment, some persons will have more or benefit more than others. This situation leads to social inequalities in society's burdens and benefits. And the ethical principle of justice clashes with individual differences and uncontrollable factors (Ludwick & Silva). A recent study on cultural dissonance among new nurse faculty can be improved by formal education, mentoring, and socialization (Schrider 2007). Two nursing interventions to improve communication and decrease ethical conflicts are to see cultural values and beliefs within historical, healthcare, cultural, spiritual and religious contexts; and to learn about the language, customs, beliefs and cultural values of these groups, especially those they encounter often. Nurses should also learn the language, customs, beliefs and values of cultural groups with whom they are most in contact (Schrider).

F. Ethical Decision-Making Model in Advanced Nursing Practice

Model G. is a seven-step method for analyzing ethical situations (Ryerson University, 2012). It was developed by Patricia Werhane and her team for Arthur Anderson and Company in 1990. This method consists of 7 questions meant to create a mental checklist of the details of the situation in making a complete construct for an ethical analysis. The questions are: what are the facts? What are the ethical issues? What are the alternatives? Who are the stakeholders? What is the ethics of the alternatives? What are the practical constraints? And what are the actions to take? These questions will bring in the most relevant factors on which to base a rational and respectful analysis (Ryerson University).

This ethical decision-making model provides a framework in identifying the difficulties and disagreements by separating the facts from the ethical issue or issues (Ryerson University, 2012). Factual questions require a different type of investigative process from…