CASE STUDIES IN NURSING ETHICS FOURTH EDITION Sara T. Fry, PhD, RN Brewster, Massachusetts Robert M. Veatch, PhD Georgetown University Kennedy Institute of Ethics Washington, DC Carol Taylor, PhD, RN Georgetown University Center for Clinical Bioethics Washington, DC 80319_FMXx_ttlpg.indd 1 6/24/10 3:31 PM World Headquarters Jones & Bartlett Learning Jones & Bartlett Learning Jones & Bartlett Learning 40 Tall Pine Drive Canada International Sudbury, MA 01776 6339 Ormindale Way Barb House, Barb Mews 978-443-5000 Mississauga, Ontario L5V 1J2 London W6 7PA [email protected] Canada United Kingdom www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. 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WY 85 F947c 2011] RT85.V4 2011 174.2—dc22 2010017881 6048 Printed in the United States of America 14 13 12 11 10 10 9 8 7 6 5 4 3 2 1 Contents List of Casesâ ix Prefaceâ xiii Introductionâ xv Part Iâ Ethics and Values in Nursing Chapter 1 Values in Health and Illnessâ 3 Identifying Evaluations in Nursingâ 4 Identifying Ethical Conflictsâ 15 Benefit to the Patient vs Benefit to Othersâ 15 The Rights of the Patient vs the Welfare of the Patientâ 19 Moral Rules and the Nurse’s Conscienceâ 23 Limits on Rights and Rulesâ 27 Chapter 2 The Nurse and Moral Authorityâ 35 The Authority of the Professionâ 37 The Authority of the Physicianâ 42 The Authority of the Institutionâ 46 The Authority of the Health Insurerâ 50 The Authority of Societyâ 52 The Authority of the Patientâ 56 iii iv Contents Chapter 3 Moral Integrity and Moral Distressâ 61 Why Does Moral Agency Matter?â 63 Moral Distressâ 63 Creating and Sustaining Healthy and Ethical Work Environmentsâ 66 Ethics Environment Assessmentsâ 67 Resources for Establishing and Sustaining Healthy Environmentsâ 67 Change Theory Modelsâ 68 Part IIâ Ethical Issues in Nursing Chapter 4 Benefiting the Patient and Others: The Duty to Produce Good and Avoid Harmâ 79 Benefit to the Patientâ 82 Uncertainty About What Is Actually Beneficial to a Patientâ 83 Health Benefits vs Overall Benefitsâ 85 Benefiting vs Avoiding Harmâ 89 Act vs Rule Consequentialismâ 91 Benefit to the Institutionâ 94 Benefit to Societyâ 97 Benefit to Identified Nonclientsâ 99 Benefit to the Professionâ 102 Benefit to Oneself and One’s Familyâ 105 Chapter 5 Justice: The Allocation of Health Resourcesâ 109 The Ethics of Allocating Resourcesâ 111 Two Meanings of the Word Justiceâ 111 Three Ways to Allocate Resourcesâ 111 Justice Among the Nurse’s Patientsâ 114 Justice Between Patients and Othersâ 122 Justice in Public Policyâ 126 Justice and Other Ethical Principlesâ 131 Contents v Chapter 6 Respectâ 136 Ignoring a Person as a Person and Focusing Only on the Pathology or “Task” to Be Performedâ 139 Arrogant Decision Makingâ 141 Humiliating Othersâ 144 Chapter 7 The Principle of Autonomyâ 149 Internal Constraints on Autonomyâ 152 External Constraints on Autonomyâ 159 Overriding Autonomyâ 164 Paternalistic Overriding of Autonomyâ 164 Overriding Autonomy to Benefit Othersâ 169 Chapter 8 Veracityâ 174 The Condition of Doubtâ 176 Duties and Consequences in Truth Tellingâ 179 Lying and Patient Well-Beingâ 179 Lying and the Well-Being of Othersâ 184 Complications in Truth Tellingâ 187 When the Patient Asks for Dishonestyâ 187 When the Family Asks Not to Tellâ 188 The Right to Health Recordsâ 192 Chapter 9 Fidelityâ 196 Promise Keepingâ 197 Explicit Promisesâ 198 Implicit Promises and the Right of Access to Health Careâ 201 Confidentialityâ 203 When the Patient May Be Harmedâ 209 When Others May Be Harmedâ 215 When Required by Lawâ 220 vi Contents Chapter 10 The Sanctity of Human Lifeâ 223 Actions and Omissionsâ 225 Criteria for Justifiable Omissionâ 229 Withholding and Withdrawingâ 233 Direct and Indirect Killingâ 238 Voluntary and Involuntary Killingâ 243 Is Withholding Food and Water Killing?â 247 Part IIIâSpecial Problem Areas in Nursing Practice Chapter 11 Abortion, Contraception, and Sterilizationâ 259 Abortionâ 260 Contraceptionâ 270 Sterilizationâ 274 Chapter 12 Genetics, Birth, and the Biologic Revolutionâ 278 Genetic Counselingâ 280 Genetic Screeningâ 289 In Vitro Fertilization and Artificial Inseminationâ 294 Genetic Engineeringâ 306 Chapter 13 Psychiatry and the Control of Human Behaviorâ 313 Psychotherapyâ 317 The Concept of Mental Healthâ 317 Mental Illness and Autonomous Behaviorâ 320 Mental Illness and Third-Party Interestsâ 324 Other Behavior-Controlling Therapiesâ 329 Contents vii Chapter 14 HIV/AIDS Careâ 333 Conflicts Between Rights and Dutiesâ 335 Screening/Testing for HIVâ 335 Balancing Confidentiality Protection and the Duty to Warnâ 339 The Rights of HIV-Infected Individualsâ 345 Conflicts Involving the Cost of Treatment and Allocation of Resourcesâ 349 Research on HIVâ 357 Chapter 15 Experimentation on Human Beingsâ 364 Calculating Risks and Benefitsâ 370 Protecting Privacyâ 377 Equity in Researchâ 380 Informed Consent in Researchâ 383 Chapter 16 Consent and the Right to Refuse Treatmentâ 396 The Right to Refuse Treatmentâ 401 The Elements and Standards of Disclosureâ 405 Comprehension and Voluntarinessâ 413 Consent for Patients Who Lack Decision Capacityâ 418 Chapter 17 Death and Dyingâ 426 The Definition of Deathâ 429 Competent and Formerly Competent Patientsâ 433 Treating Against the Wishes of the Patientâ 433 The Patient in Conflict with the Physician and the Familyâ 436 The Problem of the Ambivalent Patientâ 438 Never-Competent Patients and Those Who Have Never Expressed Their Wishesâ 441 How Much Discretion Should Family Have?â 443 Nonfamily Surrogatesâ 448 Divisions Within the Familyâ 451 Futile Careâ 458 Limits Based on the Interests of Other Partiesâ 464 viii Contents Appendixâ 473 Glossaryâ 479 Indexâ 487 List of Cases Case 1-1: The Patient Who Needed Help Getting Out of Bed 4 Case 1-2: The Nurse–Midwife and Crisis in a Home Delivery 9 Case 1-3: The Nurse and Cost Containment: The Duty to Society 16 Case 1-4: When Promoting the Patient’s Well-Being Infringes on Basic Human Rights 19 Case 1-5: The Nurse Asked to Assist in an Abortion 24 Case 1-6: The Visiting Nurse and the Obstinate Patient: Limits on the Right to Nursing Care 28 Case 2-1: The Nurse Who Thought the ANA Code of Ethics for Nurses Was Wrong 37 Case 2-2: Following the Physician’s Orders: The Nurse as Moral Spectator 43 Case 2-3: The Nurse Covering the Maternity Unit 47 Case 2-4: When Health Insurers Put Newborns at Risk 50 Case 2-5: Medications by Unlicensed Technicians 52 Case 2-6: The Patient Who Refused to Be Tested for a Genetic Disease 57 Case 3-1: The Nurse Expected to Go Along with the Doctor’s Deception 65 Case 3-2: Nurses Caught Between a Rock and a