HEALTH SCIENCE JOURNAL ® VOLUME 5, ISSUE 1 (2011)

What are the Major Ethical Issues in Conducting Research? Is there a Conflict between the Research Ethics and the Nature of Nursing?

Georgia Fouka1, Marianna Mantzorou2

1. RN, PhD, Assistant Professor of Nursing, Department of Nursing Β΄, Technological Educational Institute (TEI) of Athens, Greece 2. RN, MSc, Lecturer, Department of Nursing Β΄, Technological Educational Institute (TEI) of Athens, Greece

Abstract

Background: Research ethics involve requirements on daily work, the protection of dignity of subjects and the publication of the information in the research. However, when nurses participate in research they have to cope with three value systems; society; nursing and science which may be in conflict with the values of subjects, communities, and societies and create tensions and dilemmas in nursing. Method and material: Using the Medline and the Nursing Cinahl data base, the most important ethical issues which appear in bibliography, will be addressed. After a short description of the nature of nursing, and the advocacy role of nurses, the writer will attempt to highlight the possible conflicts that nurses have to deal with, when undertaking or participating in research. Results: The major ethical issues in conducting research are: a) Informed consent, b) Beneficence- Do not harm c) Respect for anonymity and confidentiality d) Respect for privacy. However, both the nature of nursing which focuses on caring, preventing harm and protecting dignity and the advocates role of nurses which calls for defending the rights of subjects, are sometimes incongruent with the ethics in research. Conclusions: Ethical issues, conflicting values, and ambiguity in decision making, are recurrently emerging from literature review on nursing research. Because of lack of clarity in ethical standards, nurses must develop an awareness of these issues and an effective framework to deal with problems involving human rights.

Keywords: research ethics, moral dilemmas in research, nature of nursing, nursing research, nursing advocacy

Corresponding author:

Mantzorou Marianna, 13, Tassopoulou str. Ag. Paraskevi, 15342, Tel. 210 6398958, mobile: 6937849980, Email: [email protected]

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Introduction

thics is rooted in the ancient Greek physical and mental harm, or suffering and philosophical inquiry of moral life. It death. It also emphasises the risk- benefit Erefers to a system of principles which balance.5 The only weak point of this code can critically change previous considerations was the self regulation of researchers which about choices and actions.1 It is said that can be abused in some research studies.4 All ethics is the branch of philosophy which declarations followed, forbade non- deals with the dynamics of decision making therapeutic research. It was only in 1964 concerning what is right and wrong. with the declaration of Helsinki that the Scientific research work, as all human need for non therapeutic research was activities, is governed by individual, initiated.6 The declaration emphasised the community and social values. Research protection of subjects in this kind of ethics involve requirements on daily work, research and strongly proclaimed that the the protection of dignity of subjects and the well being of individuals is more important publication of the information in the than scientific and social interests.4 research. In terms of Nursing the first inquiry was However, when nurses participate in the "Nightingale Pledge" (1983). Since then research they have to cope with three value there has been a significant development of systems; society; nursing and science. The professional codes in conduct and research. societal values about human rights, the The American Nurses' Association (ANA) nursing culture based on the ethic of caring Guidelines for Research, the Human Rights and the researcher's values about scientific Guidelines for nurses in clinical and other inquiry. According to Clarke these values research (1985) and the Royal College of may conflict with the values of subjects, Nursing Code for nurses in research (1977) communities, and societies and create provide a strong assistance to professional tensions and dilemmas in nursing.3 nurses as well as reassurance to patients, the In this paper, the most important ethical public and society, of professionals’ issues will be addressed. After a short intentions.7-9 description of the nature of nursing, and the advocacy role of nurses, the writer will Major ethical issues in conducting research attempt to highlight the possible conflicts that nurses have to deal with, when Informed consent undertaking or participating in research. Informed consent is the major ethical Historical overview- Ethical codes issue in conducting research. According to Armiger: "it means that a person knowingly, Human experimentation has been voluntarily and intelligently, and in a clear conducted even before 18th century. and manifest way, gives his consent" .10 However, the ethical attitudes of researchers Informed consent is one of the means by drawn the interest of society only after which a patient's right to autonomy is 1940's because of human exploitation in protected. Beauchamp and Childress define several cases. Professional codes and laws autonomy as the ability for self were introduced since then in order to determination in action according to a prevent scientific abuses of human lives.4 personal plan.11 Informed consent seeks to The Nazi experiments led to the Nuremberg incorporate the rights of autonomous Code (1947) which was the leading code for individuals through self- determination. It all subsequent codes made to protect human also seeks to prevent assaults on the rights in research. This code focuses on integrity of the patient and protect personal voluntary informed consent, liberty of liberty and veracity.3 Of course individuals withdrawal from research, protection from can make informed decisions in order to

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participate in research voluntarily only if science.3 According to this, the will of the they have information on the possible risks subject must be respected at any cost for and benefits of the research.12 Free and the research. informed consent needs to incorporate an Another major ethical issue is obtaining introduction to the study and its purpose as an informed consent from groups with well as an explanation about the selection of diminished autonomy which will be further the research subjects and the procedures discussed later. From what has been that will be followed.8 It is essential to discussed, it becomes clear that disclosure, describe any physical harm or discomfort, comprehension, competency and any invasion of privacy and any threat to voluntariness are the four essential parts of a dignity as well as how the subjects will be consent.5 compensated in that case.5 In addition the subjects need to know any expected benefits Beneficence- Do not harm either to the subject or to science by gaining new knowledge.8 A disclosure of alternatives The ethical principle of beneficence is also required as for example in the refers to the Hippocratic "be of benefit, do Tuskegee study about syphilis. In this study, not harm". Beauchamp and Childress, suggest rural black men were chosen as subjects in a that study of syphilis. Although a cure for syphilis "the principle of beneficence includes was found after the start of the study, it was the professional mandate to do effective decided not to treat them and they had not been told that penicillin was effective to and significant research so as to better serve their disease.13 The researcher must inform and promote the welfare of our the subjects about the methods which will be used to protect anonymity and constituents".11 confidentiality and indicate a person with Beneficence is sometimes difficult to whom they can discuss the study. He must predict when creating a hypothesis especially also provide a "Noncoersive Disclaimer" which in qualitative research. Carr says that if the states that participation is voluntary and no research findings prove that it was not penalties are involved in refusal to beneficial as it s expected, this can raise participate.14 Moreover, the subject must be immense ethical considerations especially for told that some information has been nurses.16 Ford and Reutter say that deliberately withheld in order to avoid "beneficence relates to the benefits of the altered behaviours. The researcher must also research, while non-malificence relates to take into account that persons with physical, the potential risks of participation".12 Non- cultural and emotional barriers may require malificence requires a high level of a very simple language in order to sensitivity from the researcher about what understand him.15 Finally, the freedom to constitutes "harm". According to Burns and withdraw must be explained.5 This is very Grove "discomfort and harm can be important but raises the issue of how physiological, emotional, social and difficult the subjects can withdraw after economic in nature".5 developing a personal and sometimes When a researcher tries to learn intimate friendly relationship with the researcher.12 details of the participants lives he has to With regard to withdrawal a researcher may deal with opening old wounds.12 Non- be in a dilemma in case many subjects malificence dictates both preventing choose to withdraw at an advanced stage of intentional harm and minimising potential the study, because this can affect the harm. A researcher must consider all possible validity of the results. The Declaration of consequences of the research and balance Helsinki provide some help as it declares that the risks with proportionate benefit. The the interest of the subject must always type, degree, and number of potential risks prevail over the interests of society and must be assessed as well as the patients

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value system which ranks various harms.17 moral dilemmas. In that cases it can be The risk benefit ratio can only be achieved argued that the moral duty and personal by identifying these factors. If the risks ethos can be stronger than legal outweigh the benefits, the study should be requirements.3 Even if there are no duty revised.5 conflicts, the researcher faces several Last, debriefing at the end of a study, problems with respect to maintaining should be mentioned. Treece and Treece say confidentiality especially in qualitative that debriefing refers to explaining the exact research where conduct is personal, the aim of the study and why the disclosure was sample is smaller and the reports display not full.18 Treece and Treece suggest that quotations of interviews. Ford and Reutter subjects should feel as much at ease as suggest using pseudonyms and distorting possible and express their feelings.18 In identifying details of interviews when addition, Burns and Grove suggest that if the transcribing the tapes used.12 subjects experienced a high level of In situations that are particularly discomfort, they should be debriefed or complex, sensitive, and in which the referred to appropriate professional participants are extremely vulnerable, a intervention as necessary.5 Certificate of Confidentiality issued by the U.S. Department of Health and Human Respect for anonymity and confidentiality Services (DHHS) may be useful to help ensure the privacy of research participants The issue of confidentiality and especially in studies in which participants anonymity is closely connected with the and researchers may be exposed to rights of beneficence, respect for the dignity compelled legal disclosure of research data. and fidelity.3 ANA suggests anonymity is The researchers must always bear in protected when the subject's identity can mind all psychological and social implications not be linked with personal responses. If the that a breach of confidentiality may have on researcher is not able to promise anonymity subjects. In order to protect participants, he has to address confidentiality, which is they have to inform them on their rights, and the management of private information by use all possible coding systems that they the researcher in order to protect the regard appropriate in each case. subject's identity.19 Levine advocates that confidentiality means that individuals are Respect for privacy free to give and withhold as much information as they wish to the person they The fifth principle of the entitled "A choose.20 The researcher is responsible to Patient's Bill of rights" document published in "maintain confidentiality that goes beyond 1975 by the American Hospital Association ordinary loyalty". Clarke addresses the (AHA), affirm the patient's right of privacy.21 ethical dilemma of the researcher when According to Levine : "privacy is the freedom confidentiality must be broken because of an individual has to determine the time, the moral duty to protect society.3 extent, and general circumstances under According to the utilitarian theory, which which private information will be shared focuses on the best interest of all involved, with or withheld from others ".20 the happiness of society is of greater Kelman believes that an invasion of importance. On the other hand, the privacy happens when private information deontological theory which ignores the result such as beliefs, attitudes, opinions and implies that the moral duty is what really records, is shared with others, without the matters. If a researcher, though, acts patients knowledge or consent.22 However, deontologically he may feel that he has not the American Nurses Association says that protected society. Another issue is that the different persons may held different opinions researcher may have to report confidential about when privacy is invaded. A researcher information to courts which can also cause cannot decide on behalf of other persons on

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those delicate issues. All aims, instruments are in favour of the use of such subjects in and methodology must be discussed with the research whilst others would argue strongly prospective subject and the research workers against it. Most condition their responses prior to the investigation. according to the seriousness of the research, Treece and Treece suggest that the level of potential risk and the availability whenever subjects refuse to report personal of alternatives.6 According to Burns and information as they regard it an invasion of Grove vulnerability increases the need for privacy, the researcher ought to respect justification for the use of such subjects.5 An their views.18 This may even apply to report intense analysis of potential risks and of age, income, marital status, and other benefits should be the first step of starting details that the subject may regard intimate. such a research and careful approach should They also imply that privacy can be invaded exist both in acquiring consent and during when researchers study certain groups the research procedure itself. Persons with without their knowledge and without diminished autonomy are also more identifying themselves. An example of such a vulnerable to invasion of privacy, since their study that the researcher hid his identity, right to privacy is limited in contrast to was Humphrie's study "Impersonal Sex in other's right to know. In the case of mentally public places" in which, he observed ill, family as well as employers and homosexuals during sexual activities in public colleagues have the right to know while men's rooms.18 Health care practitioners patients may not be able to see the need to be aware that "an invasion of privacy testimony of others in their own record. In may cause loss of dignity, friendship or the case of mentally ill patients, it is employment, or create feelings of anxiety, important to measure comprehension and guilt, embarrassment or shame".5 In develop valid tools for it, before obtaining conclusion, all possible measures have to be informed consent to participate in a research taken in order to protect subjects from study. In a descriptive study of Beebe and potential physical, psychological or social Smith the Evaluation to Sign Consent (ESC) damage during the research or after form was used in order to document circulation of the results.8 comprehension in 29 schizophrenia outpatients.24 Participants living in Vulnerable groups of people supervised housing were significantly more likely to require prompts than those living Nowadays, there is an increased concern alone. Participants prescribed two about vulnerable groups and whether it is antipsychotic medications were significantly ethical or not for them to be used as more likely to require a prompt than those research subjects." Fisher classifies prescribed only one antipsychotic. vulnerability as one characteristic of people According to Lasagna there are strong unable to protect their own rights and feelings among professionals who disagree welfare".23 So, vulnerable groups include with experimentation on vulnerable groups.25 captive populations (prisoners, However, the potential improvement of their institutionalised, students etc), mentally ill nursing care raises the issue of careful persons, aged people, children, critically ill consideration before rejecting or accepting or dying, poor, with learning disabilities, this kind of research. sedated or unconscious. The different opinions about their Skills of the researcher participation in research can be attributed to their inability to give an informed consent Jameton declares that in research the and also to their need for further protection three more important elements are the and sensitivity from the researcher as they competency of the researcher, the careful are in a greater risk of being deceived, design, and worthwhile expected threatened or forced to participate. Many outcomes.13 The Royal College of Nurses

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declares that nurse researchers should have What exactly does it mean to care? the necessary skills and knowledge for the Mayeroff describes caring as an interaction specific investigation to be carried out and which offers space for personal growth for be aware of the limits of personal both the carer and the cared.32 Roach says competence in research. Any lack of that caring describes precious moments knowledge in the area under research must when participants realise their common base be clearly stated. Inexperienced researchers of humanity".33 Burnard and Chapman should work under qualified supervision suggest that the most important elements of which has to be reviewed by an ethics caring are: "knowledge, alternating rhythms committee.26 in relationships and continuous changes in What is more, careful choice of method reactions to others, patience, honesty, trust, for data collection, to ensure validity and humility, hope and courage".9 reliability, are two main requirements that In Nursing however, the element of must be met in all kinds of research. The caring is undervalued because the profession choice depends on the object of the study. was viewed as "women’s work" in which, care When human beings are involved, all the is governed by sentiment and not by logic.34 ethical issues, discussed above, must be Nursing was perceived by society as an taken into account.2 extension of medicine while curing is regarded more important than "enhancing The nature of Nursing life quality" and preserving human dignity".29 On the other hand, Roach says that the cure- The nature and essence of nursing care dichotomy used to distinguish nursing reflects on human beings and their from medicine is an artificial one.33 relationship with health.27 Mckenna states As McNeil et al say, "care is the basis and that the primary scope of nursing is to help precondition of all cure".34 Swanson proposes persons to adapt in different stages of illness a structure for caring which includes which is a rather task-orientated and maintaining belief in persons, knowing the behaviouralistic approach.28 On the other other person, being with, doing for, and hand, Swanson notes that nursing views enabling.29 The last two are the most persons as a whole and health as a subjective important parts related to research. Doing and meaningful experience of integrating for, means predicting individual needs, with the environment.29 Mckenna views encouraging, performing tasks with adequate nursing's main elements as interpersonal skills and competence, protecting the interactions which involve practical actions patient from harm and preserving the but Chinn and Jacobs make hints on holism dignity. On the other hand, enabling, means as well.28,30 Literature contains diversed enhancing self-care by training, informing nursing definitions which indicates the and explaining to the patient as well as complicate and uncertain nature of it.28 assisting with finding alternatives.29 However, most authors reflect on caring as Leininger supports the thesis that:"there is the most important part of nursing. Raya no discipline that is so directly and focuses on the unique element of caring in intimately involved with caring needs and nursing while Swanson views Nursing in the behaviours than the discipline of Nursing".35 same scope as "informed caring for the well- However, caring is not unique in nursing. being of others".29,31 The ANA policy Other professions can also claim that caring statement declares that "Nurses diagnose and is an important part of their practice. It can treat human responses to actual or potential not be stated either that all nursing health problems".8 This is quite indicative of procedures include caring.29 What is more, the nurses' role, but it does not reflect the can nursing today be a synonym of caring? values, experience and passion of nursing. The vulnerability of the sick and the lack of Swanson suggests that nursing has to do with patient participation in health care, creates "science, concern for humanity and caring.29 a danger of patient exploitation by nurses.13

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The rapid change and development of According to Johnstone all professions with a nursing emerged the need for a code of morally significant relationship with a professional conduct to guide nurses in their patient ought to fulfil the role of the practice. advocate.1 The ANA Code for nurses though, refers to the nursing role of advocate in Advocacy in nursing safeguarding the well being of the client and the society.8 However, both the nature of Advocacy primarily used in legal nursing which focuses on caring, preventing contexts, refers to the protection of human harm and protecting dignity and the rights of people who cannot defend them for advocates role of nurses which calls for themselves.17 The role of nurses as advocates defending the rights of subjects, are is closely related to the purpose of nursing, sometimes incongruent with the ethics in the nurses views about humans and the research. needs of persons in health care.36 In literature advocacy is described in three Conflicts in nurses different models: The rights protection model implies that nurses helps persons to Beneficence-Non malificence understand and exercise their rights. They also aim to protect and enhance personal A common feature in professional autonomy.37 The value based decision model conduct codes and those specific to research suggests that nurses should not impose is the principle of non-malificence. The ANA decisions but assist persons to decide which Code of conduct declares that the nurse choices are most consistent with their protects the clients and the public from values. They should also support the patients' unethical, incompetent or illegal practice of confidence in their own decisions and any person.8 This statement raises the issue prevent limitations of their freedom.17 This of advocacy when nurses have to protect model is considered by Gadow in the patients from the researchers’ incompetence "existential advocacy" which focuses on the or unethical behaviour. Even if nurses are clarification and reconsideration of the certain about the incompetence of the values of the patients by self examination.38 investigator, which is usually very difficult, According to Fowler and Arrif this thesis is they have to deal with serious dilemmas. distinct from both "paternalistic and First they have to consider the fact that if consumer rights protection" and declares the patient learn that they are exposed to fundamental rights of self determination.17 professional misconduct, they may lose faith However according to Johnstone, Gadow in health care. Jameton though, believes does not provide adequate reasoning why that patient should be informed as they will self-determination is the most important appreciate the trust shown to him by value or why the human rights claim to self- frankness.13 If the researcher does not inform determination are quite different from a or compensate patient then nurses have to patients rights claim to self-determination. decide between the duty to safeguard the Last, the respect for persons model focuses well-being of patient and be loyal to them, on human dignity, privacy and self- and the loyalty to colleagues. determined choices that the nurse has to However, even if nurses decide that protect if the person is not autonomous or their duty of caring and being loyal to the self-determining.1 Murphy argues that this patient is more important, they may have to model which she calls the advocate model of deal with the hierarchical and bureaucratic the nurse-patient relationship, reflects the systems of institutions which demand loyalty basic value of nursing which is the best to subordinates to the institution. In case the possible care for patients.39 However, nurses incompetent researcher is a higher status should not be considered as being in a solely professional, nurses may be obliged to show position to act as patients advocates. loyalty, but this can conflict with loyalty to

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patients. Consequently, nurses may feel that judged are the physical and mental their patients are vulnerable and exposed discomfort or harm of subject, the and that they can not prevent it because qualifications and experience of the they do not have a voice or power to resist. supervisor, the scientific value, the adequate This is merely why many authors believe that consent procedures and the adequate it may not be possible for nurses to act as information given to subjects.43 Clark warns advocates of subjects in research. Many that there is a danger that the members may support the idea that the prohibition from have vested interests in a research.3 The the advocacy role comes from the origins and success of any ethics committee will always development of nursing as a women’s depend on the commitment and moral occupation dominated by medicine in a competency of its members. If instead of the bureaucratic system.40 patient and his needs, the central aims of Another possible issue of conflict is that the committee are personal interests, profits the caring nature of nursing with regard to and academic prestige, then nurses will have the right of patients to the best none to share their concerns with, and deal treatment/care is sometimes conflicting with with their dilemmas in research.1 Nurses, the aim of research in non therapeutic need a greater accessibility to committees studies. According to the Belmond and demand a multidisciplinary synthesis in commission the general aim of practice is to order to deal with very difficult cases.26 enhance the well being of individuals while Moreover, the committees should be less the purpose of research is to contribute to strict so as not to prevent knowledge general knowledge. This distinction development in nursing. highlights the differences in the aims of a nurse practitioner and a researcher. It is Confidentiality therefore very difficult for nurses to be engaged in studies whose aim is not directly The issue of confidentiality which is beneficial to the subject. They must though, stated as very important in the Hippocratic consider that these studies may generate and oath, is another possible issue of conflict for refine nursing knowledge. nurses either as practitioners or researchers. Another problem that nurses may have to Clause 10 of the ICN Code for nurses face is taking part in randomised control emphasises that all information obtained trials. According to Brink and Wood during nursing practice should be kept secret dedicated nurses are finding themselves apart from cases that it should be reported under pressure when they are asked to in a court, or in cases that the interests of exclude some patients from an obvious society are important.9 On the other hand beneficial treatment such as relaxation the ICN Code for nurses in research states techniques for relief of post operative pain.41 that: "Nurses acting as data collectors must So, they suggest that whenever it is possible recognise that they are now committed to to predict such problems for nurses, the two separate roles " .26 control data should be collected before According to the professional code they introducing the beneficial variable. Skodol can not reveal confidential information not Wilson implies that there should be some even to the members of the research team. provisions for alternative effective care.42 It is important therefore, to seek advice in Finally, Brink and Wood recommend that ethics committees to get approval for withholding benefits can be rectified at the disseminating the results of the data end of an experiment.41 This compensation collection including an account of what must be planned in advance so that enough happened.26 In addition, they have to deal money and time will be available. with the issue of anonymity when some In order to prevent human exploitation, features of the research make the subjects ethics committees were introduced.3 The easy to identify.15 It is very important that criteria on which the proposals are to be nurses always bear in mind that they should

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protect the privacy of the patient. The trust they have to decide whether to participate showed to them must not be jeopardised. or not.40 Hurst suggests that if nurses cannot Patients reveal information concerning their tell patients about the true research body and mind and expect them to be used objectives, they should provide a full only in a therapeutic manner. When explanation at the end of data collection.45 dilemmas according to confidentiality arise, Provided, of course, that a supervisor body trust as a basic element of a therapeutic has decided that disclosure should not be full relationship should be considered and in order not to invalidate the research maintained.9 outcome. Consent, can however, be a major Informed consent ethical issue for nurses when it involves persons with diminished autonomy, such as Nurses involved in research, have to children, aged, mentally ill etc. Nurses consider many ethical problems relating to should ascertain that consent has been the issue of informed consent. The ICN code obtained either from the individual, when for nurses in research, states that nurses as possible, or, by relatives or guardians. They practitioners may be called upon to witness must also protect the dignity and privacy of that informed and voluntary consent has such groups who are more vulnerable to loss been obtained from the subjects of research. of dignity and privacy. Nurses taking part in It suggests that they should make sure that research on children should be alert, in order patients have fully understood what has been to notice any verbal or non verbal dissent proposed, which means that they are aware which warrants exclusion of the child from of potential risks or discomforts. Nurses who the study (even if this creates conflicts with spend more time with patients are in a good the researcher.46 In the same prospect, position to judge it. In addition, they must nurses must act as advocates when ascertain that patients have understood their vulnerable groups are used in research, and right to withdraw at any time. In order to not prevent it. According to Levine, maintain the self-determination of patients, restricting these groups from research could nurses must be fully informed themselves end in disadvantaging those populations, about the study and its purpose.44 The even further, especially when research patient's consent should be obtained freely, involves no risk and a high potential for with full awareness of implications. If nurses benefit.20 find out that it was not obtained in an appropriate manner, they should inform Researcher role conflict patient and refuse co-operation. Webb suggests that the informed consent is an With regard to nurse researchers, the obligation of the researcher and no nurse International Council of Nurses declares that should obtain it on behalf of another they are not responsible for the care of professional, nor agree to give the patients. They should only intervene in case explanation as a substitute.40 If a nurse tries that "a harmful situation appears imminent". to get a consent, then the persons will feel This statement is not congruent with the obliged to participate, either because culture of nursing which is "intertwined with information is coming from their carer that the ethic of caring".3 The commitment of they trust and depend on, or, because they nurses to caring, may create dilemmas feel grateful for the care they are according to the conflict between the receiving.15 researcher's and clinician's role. Another conflicting issue is that giving If a researcher nurse provides physical or information to patients is accepted as a psychological care during an interview, the major role of the nurse; but if for the sake of results will be biased and generalisation will a research, nurses have to withhold be difficult.5 information, this may create conflicts when

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Another issue raised from the ICN "patient" and " illness". He also declares that statement, is to determine when a "harmful nursing, not as a biomedical branch, but as a situation appears imminent" and the science and art of caring, is able to start the intervention of the researcher is required.26 redefinition of research in health care which The declaration of Helsinki says that the was in the recent history dominated by the interest of the individual should prevail over biomedical "paradigm". the interests of society of science.3 This can solve some of the ethical dilemmas of the nurse, but in case the situation is not life- Bibliography threatening, the conflict remains. Burns and Grove suggest that in case that support from 1. Johnstone M. Bioethics. A Nursing the researcher is required, then, it should be Perspective. 5th edition Churchil given, but the subjects should be excluded 5 Livingstone Elsevier, 2009. from the research. They also recommend 2. Kilpi H., Tuomaala U. Research Ethics that another alternative, is to seek help in and Nursing Science: an empirical other professionals to proceed with the data example. Journal of Advanced Nursing, collection. Nevertheless, most health 1989;14: 451-458. professionals, no matter how skilled they are 3. Clarke J. Moral dilemmas in Nursing in supportive techniques will provide some Research. Nursing Practice, 1991;4(4): care if they feel that it is needed in a certain 22-25. case. 4. Oddi L.F., Cassidy, V.R. Nursing Research in the U.S.: the protection of human Conclusion subjects. International Journal of Nursing Studies, 1990;27(1): 21-34. Ethical issues, conflicting values, and 5. Burns N., Grove, S.K. The practice of ambiguity in decision making, are recurrently nursing research: Conduct, critique, and emerging from literature review on nursing utilization 5th ed. St. Louis, MO: research. Because of lack of clarity in ethical Elsevier/Saunders, 2005. standards, nurses must develop an awareness 6. Watson A.B. Informed Consent of special of these issues and an effective framework subjects. Nursing Research,1982;(1): 43- to deal with problems involving human 47. rights. This is necessary in order to come into 7. Royal College of Nursing, Ethics related terms with the issue of the researcher's to Research in Nursing, London,1977. values relative to the individual's rights 8. ANA (1985) Code of Ethics for Nurses. versus the interests of society. Professional Encyclopedia of Nursing & Allied Health. codes, laws, regulations, and ethics Available at: www.enotes.com/nursing- committees can provide some guidance but encyclopedia/code-ethics-nurses.Αcessed the final determinant of how research is on 1-7-2010. performed, rests with the researcher's value 9. Burnard P., Chapman C. Professional system and moral code. To prepare future and Ethical issues in Nursing. 3rd edition, nurses, ethics in research, must receive Bailliere Tindall, 2005. special attention in nursing curricula. The 10. Armiger B. Ethics in Nursing Research: criticism and uncertainties that arise, should Profile, Principles, Perspective. Nursing be rather encouraged than suppressed in Research, 1997;26 (5): 330-333. nursing education. Hunt suggests that in 11. Beauchamp T. L. & Childres, J. F order to liberate nursing from its Principles of Biomedical ethics, 5th ed, "technocratic impasse" ethics should be Oxford University Press, Oxford, 2001. broadly interpreted as an arena of new ideas 12. Ford L., Reutter L. Ethical dilemmas which can change professional hierarchies, to associated with small samples. Journal of open cross-disciplinary discussions, and Advanced Nursing, 1990;15, 187-191. question the concepts "abnormality",

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