Making the Hard Decisions: Ethical Care Decisions in Wartime Nursing
Janice Agazio, PhD, CRNP, RN, FAANP, FAAN Assistant Dean for Doctoral Programs and Ordinary Professor School of Nursing The Catholic University of America
Codes of ethics set forth standards of ethical conduct for nurses. However nurses involved in wartime operations, or disasters, may often have their moral compass challenged by the patient care decisions necessary under adverse conditions. Reverse triage, resource allocation, and promotion of patient autonomy present multiple challenges to meeting commonly applied ethical principles. This study used the ICN code of ethics as a framework to organize the ethical issues emerging from war time nursing. This paper represents a secondary analysis of two studies using thematic analysis to identify ethical issues encountered by military nurses during the recent conflicts in Iraq and Afghanistan. Data were collected during focused interviews from 111 military nurses. Across both studies issues as resource allocation; patient triage; cultural differences; and equitable treatment for all emerged as challenges. Nurses were at a loss at times about how to best manage the situations and recommended more education in ethical decision making before, during, and after deployment as a debriefing strategy. Similar issues have been documented in military and disaster literature indicating such challenges are not limited to the recent conflicts but cross time and location. By better understanding how nurses define, assess, and manage the ethical situations they encounter in wartime nursing practice, military nurses can better prepare for future conflicts; provide mentorship and targeted education to reduce feelings of moral distress; and promote ethical decision making t promote outcomes in accordance with nursing’s ethical codes.
Consent and Authorization
David Atenasio, PhD candidate Loyola University Chicago, Chicago, IL
The terms “authorization” and “consent” are often used interchangeably in discussions of ethics and health care. Other times, the concept of informed consent is defined as a form of authorization. I will argue that this is a mistake. We ought to keep authorization and consent distinct, as they denote two different morally transformative relationships. Consenting involves giving permission to another to perform actions that are ordinarily impermissible. Authorization entails obligating another to advance one’s interests on one’s behalf. Many medical agreements involve consenting and authorizing. By agreeing to surgery, one typically gives a health care professional permission to touch or operate on one’s person and requests that the health care professional perform the procedure on one’s behalf. But some forms of research participation may involve only consenting to the study without authorizing anyone to advance one’s interests in any way. Conversely, in giving an advance directive, one may authorize another to make medical decisions on one’s behalf without necessarily consenting to any specific procedure. By making this distinction, we can inquire into whether or not consent and authorization relationships ought to conform to different standards. It could be that the norms for a valid authorization relationship are identical to the norms of a valid consent relationship. But it may be that one relationship ought to require more stringent epistemic or volitional criteria than the other.
Medical Ethics in the Hospital: Era of Ethical Decision-Making and Standards for Consultation in the Healthcare System
Jasia Baig, B.S., M.S., Ph.D. Center for Healthcare Ethics, Duquesne University Pittsburgh, Pennsylvania
During the past few decades, the healthcare system has undergone profound changes in their healthcare decision-making competencies and moral aptitudes due to advancement in technology, clinical skills and scientific knowledge. Healthcare decision-making deals with morally contentious dilemmas ranging from illness, disability, and life and death judgments that require sensitivity and awareness of patients’ preferences and consideration of medicine’s abilities and boundaries. As the ever-evolving field of medicine continues to become more scientifically and morally multifarious, physicians and hospital administrators increasingly rely on ethics committees to resolve problems that arise in everyday patient care. The role and latitude of these committee’s responsibilities: dispute intermediaries, moral analysts, policy educators, counseling, advocating, and reviewing suggest the importance and effectiveness of a fully integrated ethics committee. Despite achievements on Integrated Ethics and progress in developing standards and competencies, there remains a necessity for improvement in ethics consultation in areas of credentialing, professionalism and standards of quality. These concerns can be resolved by pursuing various approaches using hard and soft models oriented towards education and intervention outcomes. Adopting stronger standards of quality by implementing a credentialing process, upholding normative significance for the American Society for bioethics and the Humanities’ core competencies, advocating for professional Codes of Ethics, and further clarifying best practices is absolutely vital in improved productivity, patient satisfaction and institutional integrity. Enhanced operational skills, ethical reasoning, core knowledge, credentialing and training can be achieved by professionals to enhance quality in ethics consultations.
Addressing Incivility in Nursing: Use of Moral Courage by Nurse Leaders
Kimberly A. Brooks, MSN, RN Magee-Womens Hospital of UPMC Pittsburgh, PA
Incivility, also known as bullying or horizontal violence, can take many forms from derogatory statements to physical harm. Incivility can create physical, emotional, and psychological symptoms leading to job dissatisfaction and increased turnover. Incivility can impact patient care and patient safety. Organizational impacts include: increased turnover and decreased productivity. Regulatory and professional agencies have issued recommendations for leaders of organizations to address incivility in the workplace. The purpose of the study was to determine if an educational program for nurse leaders can improve the perceived ability of the leaders to act with moral courage to address uncivil behavior. Two theories, identified as relevant to incivility in the workplace, Freire’s Oppression Theory and Kanter’s Structural Theory of Power guided this quasi-experimental design. A one group pretest-posttest was used. The study took place in a 363-bed tertiary care facility. A convenience sample of nurse leaders completed a pre-survey, education and a post-survey. Analysis was conducted on 37 matched pairs of surveys. The tool that was used was the Professional Moral Courage (PMC) Scale. It is comprised of fifteen statements divided into five themes with three statements per theme. Three areas of statistical significance were found using a paired t-test comparing the pre-survey to the post-survey scores. The results indicated improvement in two of five themes, acting morally and using a proactive approach, and in the overall score. The researcher concluded that leaders need to utilize moral courage and address incivility. By witnessing the leaders’ role modeling civil behaviors and taking action in the face of incivility, staff should also demonstrate the same behaviors.
Getting It Right: Tools for Teaching Ethical Analysis
Jill E. Burkemper, PhD Saint Louis University – Albert Gneagi Center for Health Care Ethics Saint Louis, MO 63014
When instructed to write about or discuss cases entailing an ethical dilemma, nursing students often struggle in their ability to identify the case’s ethically relevant factors and to articulate a clear argument supporting an ethically preferred response. Publications devoted to ethical reasoning in health care often fail to provide sufficient guidance for this task. This presentation will address why this task can be particularly challenging for nurses and why frameworks in popular health care ethics textbooks are insufficiently helpful. It will present an original case analysis method that has proven effective both in the presenter’s several years of teaching graduate nursing students and in her and her colleagues’ experience teaching undergraduate health care ethics courses. End of Artificial Life Ethics
Cynthia C Coleman, D. Bioethics (c) MA, RN John J Lynch Center for Ethics, Medstar Washington Hospital Center Washington, DC
Left Ventricular Assist Devices (LVAD) offer permanent CPR to patients with advanced heart failure. Some of these patients are eligible for heart transplants, others are not. It is a regulatory requirement to do psychological testing on patients prior to implant. Known complications of the therapy include major depression. Although a detailed life style consent is completed prior to implantation, yet no discussion can ever convey the difficulty of living dependent upon wires and battery packs. Three case studies of patients who requested cessation of LVAD therapy after implantation will be discussed. One patient never left the hospital after implant; the second is a married, employed man with young children who is living an independent life but is unhappy with the burdens of his equipment; the third is a woman with the onset of severe paranoia. Her family advocated for cessation, citing her pre-surgical Advance Directive. What is an ethical process relating to lifestyle consenting? What is an ethical process for honoring requests for therapy cessation? DNR orders are acceptable for medical futility, but what is medical futility in artificial life? Physicians are the ethical prescribers for implants, but are they the ethical prescribers for discontinuation of therapy? These three cases resulted in ethics consults for our center. I will share the cases and the moral distress of the nursing team related to each case.
Ethical Considerations for the Nurse Anesthetist
Michael E. Conti, PhD, CRNA Emory University Nell Hodgins Woodruff School of Nursing DNP Nurse Anesthesia Program
The operating room environment is one that is “high-stakes”, dynamic and stressful. It is inevitable that ethical concerns should arise from the pre-operative to the intraoperative and postoperative periods. A literature review was conducted to review the state of the science concerning ethical concerns facing Certified Registered Nurse Anesthetists. Ovid (Medline) and PubMed databases were queried using key words: Nurse Anesthesia, ethical concerns, ethical considerations, and perioperative period. Interestingly, there was a paucity of research related to ethical considerations and concerns related to nurse anesthesia practice. The database search produced 35 results, with the majority of articles focusing on issues related to informed consent and transfusions in the Jehovah’s Witness population. Clearly, more research needs to be conducted exploring the ethical concerns of those engaged in nurse anesthesia practice. This presentation will address the current science and identify the gaps related to this topic. The Virtues of Family Caregiving
Michael Dahnke, PhD Adjunct Associate Professor The College of New Rochelle, New Rochelle, NY
When a family member becomes ill or seriously ill, the sick person is not the only who is one affected. A chronic, debilitating, or fatal illness inevitably affects other family members, none more so than those who providing basic, daily care for the ill family member. These persons take on the common, personal, non-professional role of family caregiver. Although little is documented, family caregivers have a long history, far predating modern medicine and likely predating any system of formal medicine and care. The tasks, abilities, and motivations of family caregivers vary greatly, leaving the role radically heterogeneous and open. Research findings have has been written about the experience of family caregivers. However, in addition to this knowledge, an ethical understanding of the role is needed. This presentation will discuss an ethical model for understanding this role. It will focus on a virtue approach that will allow for a view of the role as a quasi-cohesive practice and for an analysis of the heterogeneous range of family caregivers. In addition, a virtue-based analysis will allow for a variety of morally praiseworthy models in recognition of the uniqueness of individuals’ personalities and the uniqueness of the situation of any individual caregiver. Restricted Permissibility for Procuring Solid Organs from Infants with Anencephaly
Brian S. Carter, MDa,b,c and Michael J. Deem, PhDd,e aDivision of Neonatology and Fetal Health, Children’s Mercy Hospital; bChildren’s Mercy Bioethics Center; cUniversity of Missouri – Kansas City School of Medicine; dSchool of Nursing, Duquesne University; eCenter for Healthcare Ethics, Duquesne University Kansas City, MO; Pittsburgh, PA
Anencephaly is a lethal malformation of the central nervous system (CNS) in which the forebrain, cerebellum, cranium, and scalp do not fully develop, leaving an open and exposed rudimentary CNS. Brain stem structures are typically functional. Most cases of anencephaly result in still-birth or death within 7 days of live-birth. When it is diagnosed prenatally, parents might inquire about the possibility of voluntarily making their child’s organs available for donation after birth. Such requests are declined by fetal health centers and organ retrieval services on ethical and policy grounds. Since 1999, only rare cases of solid organ procurement have been documented, occurring in the UK. In this presentation, we argue the traditional normative framework used to assess the ethics of pediatric organ donation is ill-suited for determining whether and when organ donation by anencephalic infants is ethically permissible. We will briefly review this framework and how it has shaped policy. We then will argue that two key elements of this framework cannot be readily applied in cases involving parental request for organ donation involving anencephalic infants: (a) the rule of Donation after Brain Death (DBD), and (b) the best interests standard as a guide to pre-mortem interventions. Specifically, we argue that (a) is not applicable to cases of anencephaly, and that (b) is an inappropriate normative guide for assessing pre-mortem interventions and benefits for infants who have a lethal condition like anencephaly. We conclude by sketching narrow parameters within which solid organ donation by anencephalic infants may be ethically permissible.
Parsing Out the Hope from the Hype in Genomics
Katherine Drabiak JD, Assistant Professor College of Public Health, University of South Florida HEALTH 13201 Bruce B. Downs Blvd., Tampa, Florida 33647
Both clinicians and the public are bombarded with enthusiastic promises of how genomics technology will improve the diagnosis of disease, offer precision treatments and cures, and create healthy children through novel fertility treatments. Scientific and popular media characterize genetic testing, genome editing, and technologies such as mitochondrial replacement therapy (“three person IVF”) as efficient and revolutionary. This presentation will discuss three examples in the genomics revolution: (1) genetic tests used in precision oncology; (2) genome editing designed to cure monogenic disease; and (3) experimental mitochondrial replacement therapy to treat infertility. The presentation will briefly distill the medical rationale for each technology, the state of the scientific evidence pertaining to potential safety and efficacy, legal and regulatory status, and provide examples of how the genomics framework constitutes only one component when addressing human health and disease. This analysis offers insight to clinical discussions that are aligned with beneficence, non-maleficence, and that increase the transparency of clinician-patient communication. The content of this presentation will provide clinicians the information to become more discerning when evaluating genomics’ promises, enabling them to accurately communicate potential risks and benefits of emerging genomics technology both inter-professionally and to patients.
When Acts Belie Principles: The Incongruity of Academic Leaders or Senior Faculty Who Violate the Nursing Code of Ethics
H. Michael Dreher, Ph.D., RN, FAAN, ANEF Associate VP for Healthcare Innovation & Special Projects The College of New Rochelle New Rochelle, NY
The nursing literature is replete with discussions addressing incivility in nursing education. Most of this literature focuses on the uncivil behavior of Student-on-Faculty and Student-on-Student and, to a lesser extent, Faculty-on-Student and general Faculty-on-Faculty dyads. A much- overlooked set of dyads, Academic Leader-on-Faculty and Senior Faculty-on Junior Faculty, is a less discussed form of incivility. While there is a large body of literature and media attention of “bullying or mean bosses” in the business world, this issue has been largely ignored in nursing higher education. The reasons for this near absence are manifold. No one would deny that incivility, bullying, relational aggression or lateral/ horizontal hostility by academic leaders or senior faculty (including mobbing) exists; however, it is rarely discussed in nursing circles and the nursing literature. Its prevalence and impact on individual faculty and the larger academic nursing organizational unit certainly warrants greater examination. In this discussion, the rationale for why these dyads have not been the focus of a broader ethical discussion is presented. One reason is that this problem presents an obvious paradox, as nursing, by its own definition and history, is characterized as a “caring profession.” It is certainly unsettling that there is incivility among nursing students (future nurses) or among nursing professors (supposedly role models). The consequences of Senior Faculty (who usually exert significant influence) and Academic Leaders (responsible for ensuring a civil/ethical work environment) engaging in these behaviors are even more troubling. When the individual or collective actions of leaders and senior faculty belie or violate the principles of the Nursing Code of Ethics, the academic nursing unit may be significantly damaged. In the many cases reported anecdotally, ethical leadership and ethical conduct were in short supply. A robust discussion is required to address this ethical problem. /Department of Nursing (responsible for ensuring a civil/ethical work
How Healthcare Professionals Manage information and Ethical Challenges within the Clinical Context: A Systematic Review of Empirical Literature
Cornelius Ewuoso MA, M.Sc. Centre for Applied Ethics, Faculty of Arts University of Stellenbosch Western Cape, South Africa
Susan Hall, PhD Centre for Applied Ethics, Faculty of Arts University of Stellenbosch Western Cape, South Africa
Kris Dierickx PhD Centre for Biomedical Ethics and Law Katholieke Universiteit De Leuven, Leuven, Belgium.
This presentation is a systematic review that assesses how health care professionals manage information and ethical challenges within the clinical context. The study’s methodology follows the Preferred Reporting Items for Systematic Reviews and meta-Analysis. We carried out a literature search in PubMed. Additional searches were also carried out in Google Scholar and Embase, using two search strings. All searches generated 665 hits. After screenings for language, title and abstract and full texts, 47 articles were selected for review. 7 other articles were identified through snowballing, bringing the total number of articles for review to 54. We used Q-sort technique for the analysis of identified articles. This study revealed that health care professionals generally employ four broad strategies/approaches for managing four broad types of challenges. The broad types of challenges include: confidentiality-related challenges, communication related challenges, professional duty related challenges and decision-making related challenges. The strategies include: resolution, consultation, stalling, and disclosure/concealment. The result of this study provides insight into how health care professionals manage information and ethical challenges. These insights complement efforts to enhance the information management skills of health care professionals within the clinical context. This review suggests that the gap between theory and practice has not been successfully bridged by current medical ethics’ frameworks. On- going reflection, directed towards the development of guidelines/frameworks for bridging this gap is urgently required to enhance health care professionals’ confidence in clinical settings. Perinatal Care of Incarcerated Pregnant Women: Managing Conflicts between Nursing Ethics and the Law
Ginette G. Ferszt, PhD, RN & Lorie S. Goshin, PhD, RN University of Rhode Island; Hunter College in the City University of New York Kingston, Rhode Island; New York, New York
The United States has the highest female incarceration rate in the world. There are approximately 112,000 women in federal and state prisons and another 110,000 in jails. Accurate figures on the prevalence and incidence of incarcerated pregnant women are difficult to obtain given inconsistent pregnancy testing and reporting requirements. However, in 2015, it was estimated that 3-10% of women are pregnant when they enter prison or jail, and approximately 1400 babies are born to women in custody. In some states, pregnant incarcerated women are routinely shackled during pregnancy and postpartum recovery in hospital settings. Shackles can create life- threatening health risks for the mother and her unborn baby. The practice contravenes nursing ethics and international human rights norms. Currently, there are only twenty-two states and the District of Columbia that have legislation restricting the use of restraints on incarcerated pregnant women. Consequently, perinatal nurses in hospital settings may care for incarcerated pregnant women who are shackled during all or part of their stay. Even when nurses ask that the shackles be removed, correctional officers may refuse, leaving nurses with moral distress, frustration and powerlessness. Drawing on our advocacy and research on perinatal care for incarcerated pregnant women, this presentation will discuss successful nursing strategies for managing conflicts between nursing ethics and the law when providing care to this population. Having an understanding of these approaches will empower more nurses to adhere to ethical and safe nursing practice while addressing potential legal concerns of correctional officers.
Nursing Strategies for Overcoming Implicit Bias
Michael B. Funke, PhD Department of Philosophy Central Washington University Ellensburg, WA
Nurses do not always like their patients; sometimes patients (or diseases) are scary, upsetting or just unfamiliar. Patients can be rude. Sometimes nurses recognize their own biases and other times they do not. As a professional it is important that nurses be able to fulfill their obligations to patients in spite of their biases. Sometimes, overcoming bias is a matter of moral strain-- trying harder. However, moral strain cannot adequately address problems associated with implicit bias. Implicit bias presents a special problem because the person is unaware of the need to exert moral strain. Even when there is awareness of bias, it is difficult to overcome predispositions in hurried, messy, or, otherwise difficult situations. More effective self-control can be an outcome of personal policies which limit the opportunities to misbehave. This essay contributes to a growing literature on the need for procedural mechanisms of self-control to avoid implicit bias. State laws, codes of ethics, hospital policies, and guidelines offer some procedural mechanisms for control. However, the hallmark of professional work is self- regulation; it is vital that nurses have strategies to regulate their own behavior. Effective and ethical nursing involves learning to recognize and control personal feelings about patients. Physician Assistance in Dying, Disability Rights, and Medical Professionalism: Developing a Virtue-Based Approach through Narrative Ethics
Peter J. Giannopoulos, Ph.D. Post-Doctoral Teaching Fellow Department of Philosophy, The Pennsylvania State University University Park, PA 16801
Commentators regularly mobilize deontological or consequentialist arguments within a framework of liberal norms to evaluate the moral permissibility or impermissibility of physician assistance in dying (PAD). In bioethics more broadly, some worry that this approach reduces ethical issues in healthcare to calculations of how to meet the moral minimum of obligations, ignoring the role of moral ideals, moral excellence, and supererogatory conduct. Perspectives endorsing virtue ethics in bioethics, medical professionalism, and healthcare are not new. However, virtue ethics in the context of end-of-life care has yet to make a significant impact on the debates over PAD. This paper contributes a virtue-based approach to PAD through examining recent work on narrative ethics in healthcare. By developing a dialogical virtue ethics, it takes into account concerns about how end-of-life decision-making impacts the disability-rights community and seeks to respond to the call for developing a disability moral psychology in bioethics. It suggests a new role for virtue in medical professionalism, where one prominent tendency has been to focus on reviving professionalism through addressing wider social injustices in healthcare rather than on end-of-life support and counseling.
Adults with Autism: When Parents Age out of Being the Care Giver: Where do They Go?
Ruth Irwin, PhD, RN Assistant Professor Duquesne University School of Nursing, Pittsburgh, PA
Autistic aloneness can be a unique characteristics present in children. Its predominate feature is characterized as being self-absorbed and ignoring the outside world. Autism, now referred to as Autism Spectrum Disorder (ASD), extends along a continuum where some persons express high intellectual abilities while others need supervision. Some adults with Autism may exhibit child- like acting out behaviors, solitary play, temper tantrums, yelling, being easily frightened, acting out, appearing aggressive, or expressing inappropriate sexual desires. This behavior by an adult can be frightening to others. Approximately, 1 in 68 eight years old children are diagnosed with Autism. It is difficult to track the true number of people diagnosed with ASD, especially as they age. However, 81% of adults with ASD live in their homes with aging parents. Living arrangements are determined by income, available community group home settings, and county waiver resources. Although adults with autism die 16 years earlier than persons without Autism, adults with Autism are often placed on long waiting lists for available residential homes specific for adults with Autism and/or on lists to obtain the correct county waiver for eligibility for services. Autism is not well understood or funded. Where will these adults live when the parents are no longer able to care for them? These are ethical and policy questions that need to be discussed.
Clinical Knowledge Development: Continuity of Care of Wounded Service members: An Ethical Perspective
Patricia Watts Kelley, PhD, FNP-BC, GNP-BC, FAANP,FAAN Professor & Director of Veterans to Bachelor in Nursing Program Duquesne University School of Nursing, Pittsburgh, PA
This presentation reports the findings of study of first person accounts of experiential learning of nurses caring for wounded service members and accounts of wounded service members’ (WSMs) memories of their care experience from point of injury in the combat zone through rehabilitation. Descriptive interpretive, ethnographic methods were used and data were collected via semi-structured private interviews with individuals or small groups: 235 nurses (Army, Navy, AF, and Federal and VA nurses and 67 WSM’s (Army, Navy, Air Force, Marine and National Guard). Interviews elicited narrative examples of nurses’ caregiving experiences and the injury, care, and rehabilitation experiences of the WSMs. Ethical questions resolved around 6 themes: resources/allocation; service issues; military nursing core values; nursing’s Code of Ethics; caring for the enemy; and need for follow-up/closing the loop.
Military medical personnel (soliders and their healthcare providers) reported extremely difficult ethical dilemmas related to the delivery of care in austere and dangerous environments according to the military code of war and rules of engagement while protecting themselves and their patients, service members, civilians, military combatants and insurgents.
Ethical challenges are not always resolved by the use of ethical reasoning processes. Some ethical dilemmas, explicated by study subjects, were ethically insoluble dilemmas. Courses that address ethical decision-making processes that address ethical dilemmas in poorly structured environments and integrate and accept decisions made in the war situation.
The Power of the Pen – Ethical Considerations When Prescribing Treatment
Sister Thea Krause, CSFN, PhD, ACNP-BC VA Medical Center Altoona, Pennsylvania
It is hard to imagine in today’s American healthcare environment that a provider may be unfamiliar with the cost of treatment options they prescribe for patients. The products and services are many and well-intentioned providers tend to choose treatments with which they are most familiar. While they cannot be expected to understand in detail thousands of drugs available in the market, they have a responsibility to know those they prescribe. Often, providers develop a keen familiarity with at least three to four drugs in each category of medicine. Knowing those drugs means knowing their purpose, side effects, interactions, treatment efficacy, costs and most importantly when they should not be prescribed. This presentation considers the ethical implications of prescribing a treatment when prescribers fail to consider cost in the decision making process. Using a case study approach, the presentation will engage the audience in analyzing the conflicts (ethical dilemmas) that can arise when prescribers fail to discuss with patients the financial implications of prescribing a costly drug. The concepts of resource allocation, financial toxicity, common good and professionalism will be explored during the case study discussion. Those present will be able to identify the costly power of a prescriber’s pen and the complications that arise when patients are not part of treatment decisions
The Issue of Stress of Conscience and Moral Injury in the Ethical Climate of Nursing: An Investigative Study
Theresa Kyzar, PhD, MSN, RN, MBA Assistant Professor BSN Campus Coordinator Northwestern State University Natchitoches, Louisiana
Abstract Personal conflict can occur for the nurse when healthcare decisions cause internal moral or religious conflicts resulting in a stress of conscience. The healthcare organization’s ethical climate also plays a vital role in the nurse’s chosen work environment and its work climate as a determining factor for behavior. In the realm of daily patient-care activities, the nursing unit’s climate can serve as the foundation for support mechanisms, which nurses may utilize when coping with difficult situations moderate the effects of moral stress and injury. How nurses view their work, environments may determine if nurses raise ethical concerns among other nursing staff members and/or if the concerns are resolved. The ability to address many of the dilemmas experienced by nurses can be affected by the ethical climate of specific practice areas. The implication regarding the role of conscience and moral injury among health care providers, including nurses, remains an unsettled area in bioethics. Ethical dilemmas may lead to moral distress in nurses. This presentation discusses a recent quantitative study of registered nurses in one southern state that investigated registered nurses’ attitudes regarding the role between conscience and ethical climate in acute care environments. Consideration will be given to moral injury and strategies to promote resilience in the workplace that may enhance staff retention efforts in hospitals.
Beyond Morality and the Clinic: Contemplating End-Of-Life Decisions
Yael Lavi School of Philosophy, Linguistics and Science Studies, Tel Aviv University Tel Aviv. Israel
This article argues that the current discussion on “Voluntary Death” is limited to moral and clinical-scientific perspectives, which, due to their structural limitations, minimize the philosophical-existential possibilities inherent in the issue. Its first section of the presentation offers an interpretative analysis of the shaky ground underlying the moral debate over suicide. Following Anscombe’s critique of the incomprehensibility of the terms “good” and “duty” in moral systems not based on divine authority, I highlight three fundamental deficiencies of this argument: reliance on an erroneous conceptual framework, deviation of the discussion regarding life’s assessment as ‘good’ or ‘desirable’ from the fundamental issue, and slippage into the narrow narrative of pathology. The second section addresses the failings of the clinical- scientific discourse on suicide, which is focused and disciplinary and therefore always partial, whereas the description and interpretation of “end-of-life” decisions require a broad, stratified, and complex explanation. Moreover, its scientific language lacks tools to contend effectively with that which cannot be expressed in formal language and suffers from an a priori assumption that choosing death is neither normal nor rational. Finally, its rootedness in the structure of language and religious moral thought also makes Anscombe’s criticism relevant here. The third section expands the discourse beyond morality and clinical considerations into a conceptual and nonjudgmental space. In the wake of Cora Diamond, I show how such a discussion not only explains and clarifies but also expands the boundaries of language, shaping and changing the ethical reality itself. Deciding Together: Promoting Relational Autonomy in Advance Care Planning
Julie Murphy MSN, RN, PhD Candidate The Pennsylvania State University University Park, PA
Currently 2.5 million Americans die each year, yet only 1 in 5 have discussed or documented their end of life preferences. Despite nearly 30 years of scientific and legislative efforts, advance care planning has yet to become commonplace in America. Most persons desire to have their families involved, yet often these critical advance care planning conversations do not take place. Inviting and integrating the family into these, conversations could provide an avenue to have decisions made at the end of life more congruent with a person’s preferences. Following an examination of bioethics literature exploring how relational autonomy plays a vital role in family communication and the ability to engage in critical advance care planning conversations. The author will argue that there is a paucity of research linking relational autonomy, family communication and the ability of adult children to participate in and discuss advance care planning with their parents. Most people express a desire to have their family involved, yet barriers exist within the advance care planning process, further supporting the role of relational autonomy. Suggestions for identifying and capitalizing on family communication patterns, through a relational autonomy framework for promoting frequent and earlier conversations can lead to decisions being congruent with a person’s end of life wishes. These critical conversations could also decrease negative outcomes associated with decision making as a parent approaches the end of life.
Can Persisting Ethical Quandaries in International Biomedical Research be Resolved? Critical Analysis of Specific Ethical Debates and Concerns Regarding International Research
Persis Naumann B.Tech in Biomedical Engineering, M.A. in Healthcare Ethics Ph.D. Student Center for Healthcare Ethics, Duquesne University Pittsburgh, Pennsylvania
Biomedical research is indispensable for the development and sustainability of healthcare. Over the years, research has grown enormously and the process of doing research is becoming more complex. Additionally, with the proliferation of globalization, in research activities, such as international research, organizations that increasingly go beyond geographical boundaries and have world-wide scale, promote greater interdependence worldwide. The ramifications and implications of internationalization of research can affect people all over the world due to its global nature. Following every major scandal in research when key ethical norms are violated, or in cases of scientific misconduct, there is call for framing ethics for protecting human subjects in research. Although fundamental ethical dilemmas still persist in international research, several dubious trials have created controversies and brought to light concerns over three main issues in international research including response to health needs and priorities of host communities, prior agreements about future access to medicine and intervention, and the notion of autonomy and the process of informed consent in a culturally, politically, and ethically pluralistic society. This paper critically analyzes specific ethical debates and concerns regarding international research. The analysis begins by explicating the globalization of biomedical research focusing on the global pharmaceutical and contract research organization market, then critically argues the key ethical implications due to the internationalization of research, and concludes by advocating for a creative, collaborative, and collective partnership approach to conduct ethically robust international research.
Protection or Paternalism?Rethinking the Ethics of Research with Vulnerable People
Judith Navratil, MA CIP Faculty Research Liaison Human Research Protection Office University of Pittsburgh Pittsburgh, PA
A central requirement for the ethical conduct of research is the fully informed consent of a competent individual who is free to exercise his or her own will without restriction and free from duress. Research involving an individual who does not meet these prerequisites is ethically problematic. Vulnerable persons, defined by Robert Levine as those who are “relatively (or absolutely) incapable of protecting their own interests,” include children, prisoners and adults with impaired cognitive capacity. Federal regulations require these persons be afforded additional protections by requiring the proxy consent of a legally authorized representative. In this session, I discuss the possibility that Institutional Review Boards (IRBs) rely on proxy consent to protect cognitively impaired adults and children in cases where it is not appropriate, and neglect the requirement that the subject should be asked to provide his or her own assent for participation. I will present examples of research designs that involve vulnerable subjects where proxy consent may not be necessary or appropriate. The Belmont Report points out that the exact nature and extent of protections for vulnerable persons should be based on the circumstances at hand and correspond to the risks and potential benefits of the research. It must also be based on a judgment about the extent of the individual’s incapacity: “Some persons are in need of extensive protection, even to the point of excluding them from activities which may harm them; other persons require little protection beyond making sure they undertake activities freely and with awareness of possible adverse consequence.” I will also discuss the characteristics that make a particular research subject vulnerable, and suggest a variety of possible protections that should be extended to vulnerable research subjects depending on the nature of the risks posed and the extent of the individual’s capacity. Medical Gawking and the Temptation of Social Media: Reinforcing Dignity amongst Health Care Professionals
Cameron R. Nelson, JD, LLM, BSN, RN U.S. Navy Arlington, VA
Participating in a patient’s care is a distinct privilege, and all health care professionals must protect the dignity of not only the patient, but also their profession. Recently, several high profile examples of “medical gawking” demonstrate a failure to protect that dignity. Medical gawking is a term often used to describe health care professionals who observe or document clinical care without clinical purpose, educational requirement, or without the patient’s informed consent. The risk of harm to the patient increases when the gawker introduces the inappropriate use of social media to preserve or disseminate images. A review of recent examples of medical gawking and social media usage, in both military and civilian hospitals, offers a critical framework to reinvigorate ethical decision-making that protects dignity. The health care professional must consider whether an action is clinically necessary. Passive observation may offer educational benefit; however, observation for the purpose of entertainment or humor violates the patient’s dignity. By focusing on the motive to observe care or disseminate images documenting a condition or treatment, the health care professional will be able to quickly identify violations of dignity and increase ethical decision-making in the clinical setting. Simulating Ethical Issues in Pediatric Nursing
Laura Nold MSN, RN Instructor Missouri Western State University St. Joseph, MO
One critical issue confronting nurse educators is preparing students to face and appropriately handle ethical issues in their future careers. Pediatric nursing is a particular area that presents opportunity for many ethical issues to arise. Simulation is one area in which we can incorporate these ethical dilemmas and issues to provide a safe space in which students can work through these situations. In this pediatric nursing course, the instructor has sought to utilize creative strategies in simulation to provide hands-on education regarding ethical issues in healthcare. One particular simulation developed and implemented focuses on child abuse and neglect, with emphasis on the nurse’s ethical responsibility in that difficult situation. Attention is placed on caring for the child and family including appropriate referrals and interventions. Debriefing involves conversation around the ANA Code of Ethics and ethical issues specific to the pediatric setting.
Acting on Values: Different Problems Need Different Approaches
Douglas Olsen, RN, PhD Associate Professor Michigan State University East Lansing, MI
This presentation begins by showing that nursing practice is dictated by moral values and then specifies the ways nursing ethics applies values to practice. A method for pinpointing values by identifying the ideas, concepts, and beliefs one uses to determine that a particular outcome is better than another outcome will be introduced.
While nursing develops and uses empirical evidence to determine the clinical effects of intervention, this method serves nursing goals governed by moral values. Nursing ethics analyzes values in relation to practice in four ways: 1) Identifying wrongdoing, that is, violations of our values; 2) Identifying situations where values conflict, that is moral dilemmas; 3) Seeking better ways to enact professional values; and 4) Determining what ought to be our professional values. When considering an ethical situation, determining which of these types describes the circumstances is useful because each type of problem requires its own approach to resolve or improve the situation. Labeling each type of problem as “ethical” without further distinction may lead to confusion regarding how to address the problem and the appropriate outcome. For example, wrongdoing will not be resolved with ethical analysis, and compelling compliance of those with whom disagrees will not resolve dilemmas. The presentation will provide examples of each type of problem, suggest appropriate questions to determine categories, and offer approaches for reaching resolution.
Heeding Humanity in an Age of Electronic Health Records
Casey Rentmeester, Ph.D. Bellin College Green Bay, WI
The American Recovery and Reinvestment Act of 2009 (ARRA) required healthcare providers in the United States to adopt and demonstrate meaningful use of electronic health records (EHRs) by January 1, 2014. In many ways, EHRs mark a notable improvement over paper medical records since they are more easily accessible and allow for electronic searching and sharing of medical histories. However, since EHRs have become mandated by ARRA, many nurses now rely upon computers during nurse-patient interactions, thereby decreasing the level of direct interpersonal communication. There is evidence that eye contact between nurses and patients positively affects patient satisfaction. Above and beyond the issue of patient satisfaction is the more basic ethical issue of respecting the patient as a person. How can we ensure that the nurse- patient experience is not thoroughly mediated by technology that we may risk the loss of respect for the patient? The author argues that the templates used in electronic health systems like Epic, the most used healthcare software in the United States, have the possibility of eroding the respect for humanity that is the hallmark of nurse-patient relationships. Respect for the dignity of the patient is the first principle of the American Nurses Association in their Code of Ethics. Using concepts from philosophers Martin Heidegger and Emmanuel Levinas, the author provides guidance as to what an ethical interaction between nurse and patient should look like in an age of EHRs. Male Neonatal Circumcision: Current Practices and Ethical Issues
Alex Sargsyan, DNP, ANP-BC, CNE, RN Assistant Professor College of Nursing East Tennessee State University
In 2012 the American Academy of Pediatrics (AAP) revised its recommendations regarding neonatal male circumcision, transitioning from a recommendation against it to endorsing the practice. The current recommendations are based on the findings of three studies performed in Sub-Saharan Africa. In those studies, the researchers suggested that circumcision may result is reduced rates of Human Immunodeficiency Virus (HIV) transmission via heterosexual intercourse. In addition to the above studies there are several studies suggesting that circumcision can have benefits in reducing the rates of penile cancer, human papilloma virus transmission, and urinary tract infections. Based on the AAP recommendations some third-party payers have revised their policies regarding reimbursement procedures. While circumcision practices are a topic of debate in the United States, non-therapeutic circumcision is not recommended by the European Academy of Paediatrics and is not reimbursed by third-party payers. For instance, the National Health Service in Great Britain discontinued the practice of routine non-therapeutic circumcision in the mid twentieth century. This presentation will give a thorough review of the existing body of knowledge regarding the practices of non-therapeutic male infant circumcision. Existing studies regarding HIV risk reduction will be discussed in detail. At the same time, the generalizability and transferability of the above studies to the US health care system will be discussed. Finally, third-party reimbursement practices, costs associated with circumcision, and ethical issues related to this issue will be discussed.
Research Integrity Challenges in Developing Countries
Dina Siniora, MBA, PhD (second year) in Health Care Ethics (and Graduate Assistant for Dr. Gerard Magill) delete?, Duquesne University
Andrew Faramnd, MD, Msc. In Clinical Neuroscience (UCL), Researcher at Neurosurgery Department, University of Pittsburgh Medical Center
Research integrity addresses adherence to high moral codes, values and professional principles, supplemented by professional institutions and research organizations. The concept of vulnerability is reflected in guidelines that address research integrity. Informed consent, the base of bioethics, is a tangible indication of respect for people, particularly for vulnerable populations. It aims to protect the human dignity of research participants and the rights of researchers. Nevertheless, it is an insufficient means to protect participants from exploitation.
In developing countries, several factors: lack of access to health services, reduced autonomy, lack of awareness of human rights, illiteracy, poverty and lax regulatory oversight can undermine the integrity of the research and increase the likelihood that vulnerable people are exploited. Researchers need to manage the social, political, and environmental factors in developing countries that can aggravate human vulnerability and threaten the integrity of the research.
Personal Smartphone Technology Use at the Bedside: Ethically Speaking, do the Pro’s Outweigh the Con’s?
Sally J. Spooner, DHS, MSN, RN Nova Southeastern University Ft. Myers, Florida
The nursing profession is seeing a changing of the guard. As the Baby Boomer generation retires, the Millennial generation continues to replace them at the bedside. With the continued evolution of technology and a generational change within the profession of nursing, the literature reveals concerns that millennials may not act ethically in using the technology that they have grown dependent upon. Technology is a major component of the Millenial lifestyle. They are rarely without their smartphones and their need to be connected to social networks raises concerns. Concerns focus on: breaches of patient confidentiality, patient privacy and distractions that could cause novice nurse to neglect or to cause harm to patients. Authors note Millennials expertise with smartphone technology. One thing is certain, technology continues to evolve as surely as the Millennial generation continues to replace the Baby Boomer generation at the bedside. This presentation will look at the pros and cons of technology and the perceptions of millennial nursing students about their smartphones.
Using an Interdisciplinary Team Meeting Approach to Ethics Consultation
Sarah Stockey, DHCE Duquesne University Pittsburgh, PA 15236
Ethics consultation in a hospital or other healthcare facility should not be limited solely to the work of ethics consultants. Instead, the process should include a team of healthcare professionals across all aspects of the patient’s care in order to have the most thorough analysis of the situation. Nursing professionals are particularly important to this process. It is the bedside nurse, as well as the unit nurse manager, who have more information about the day to day and hour to hour status of the patient, including the patient’s physical, psychological, social, and spiritual condition. These nurses also work closely with the physicians to get a clearer and accurate understanding of the care plans being recommended for the patient. Using a team meeting approach to ethics consultation and relying on the input of all caregivers, including nurses, the ethics service of a facility can more clearly work towards preventive ethics and overall improved education within the facility. Using the Integrated Ethics model established by the VA, it can be established that including all disciplines of healthcare in the consultation process can improve the ethics culture and environment of a facility. This integration can also better enable the various specialists to identify and even address potential future ethical conflicts before a full consultation may be needed. This preventive measure can improve the overall ethics quality of the services rendered in a facility. Evaluating Dual Agency in Nursing Practice: How to Make a Choice of Right Action
Liz Stokes, JD, RN Senior Policy Advisor American Nurses Association Center for Ethics and Human Rights
This presentation will use case based learning to evaluate ethical decision-making in nursing practice settings where there are competing ethical obligations. Three examples will be discussed and one case will be fully evaluated.
1) A military nurse is asked to perform force-feeding of a detainee who is on a self-imposed hunger strike. Is this for the benefit of the patient, the military, or aligned with the health care providers professional ethical obligations? 2) A corrections nurse is asked to participate in security activities such as hostage negotiations or punitive disciplinary procedures. Could this type of action negatively affect the nurse-patient relationship? 3) A sexual assault nurse examiner is asked to collect evidence from an incoherent victim who is unable to give consent. It appears that there may be competing roles as the nurse is working as a health care professional, but also under the auspices of the police department. Is the nurse’s duty to the patient or to law enforcement?
How does one consider professional nursing ethics in a setting that demands one practice, but professional or moral obligations demand another ethical action? How does a health care practitioner make a choice of right action? In these circumstances, healthcare providers are often forced to make time-sensitive ethical decisions weighing principles of beneficence, non- malfeasance, justice and the respect for autonomy. The discussion will focus on ethical decision- making and moral courage in situations with competing professional or moral obligations.
Using Technology Tools to Teach Ethical Decision Making
Kay Swartzwelder, PhD, MSN, FNP-BC, CNE Jackie Murphy, MSN, RN, CPN, CNE Drexel University Philadelphia, PA
This presentation discusses the theory behind collaborative learning, a brief overview of research on traditional discussion board vs video discussions, an overview of the technology tools used to teach ethical decision making with a focus on parental autonomy and cultural tolerance. Social learning theorists of the past identified the importance of social influence on the learning process. The common theme is the belief that students do not learn in isolation, therefore instructional strategies that allow for interaction via discussions between learners will enhance learning. Quantitative data were collected from a convenience sample of 163 students enrolled in an online ethical decision making course to determine student preference between text based and video based discussions. Although new technologies can reach varied learning styles of students, it is important to focus on a multi-modal approach using traditional text based discussion boards and video discussions can present ethical issues and allow students to express their thoughts and view opinions that differ from their own. Based on the findings from the study, a challenge video was presented on genetic engineering and cultural tolerance. Students then presented a video argument about the issues via a three-minute video posted to DB for peer discussion. An enhanced understanding of various viewpoints on ethical issues will be discussed through the use of two modes of student interaction. The Experiment Requires that You Continue
Bekka Williams, PhD - Assistant Professor of Philosophy Minnesota State University, Mankato Mankato, Minnesota
Standard Institutional Review Board practice requires that enrolled study subjects who express the wish to discontinue study participation after they lose the capacity to give informed consent must always be removed from the study. Against this practice, I argue that there are (at least in principle) possible cases in which, from the moral perspective, a no-longer-competent study subject ought not to be removed from a study due to currently-expressed unwillingness to continue. Crucially, I first defend the position (likely assumed, but not explicitly addressed, in the existing philosophical literature) that those who lack the capacity to consent to interventions also lack the capacity to revoke consent to interventions. I then argue that, in the absence of revoked consent, there are (at least) possible cases in which the moral value of respecting a subject’s (prior) autonomous decisions outweighs the importance of respecting that patient’s (current) non-autonomous wishes. In arguing for this position, I rely especially on Ronald Dworkin’s (1993) defense of the view that it is the value of individual integrity, rather than a direct concern for well-being, that grounds the moral importance of respecting individual autonomy. I conclude with a discussion of whether the legal (as opposed to moral) importance of “erring on the side of caution” might justify a blanket policy of removing no-longer-competent study subjects who express unwillingness to continue even if there are cases in which such removal is not morally obligatory.
Selective Adherence to Treatment Plans: Prix Fixe or A la Carte?
Rebecca B. Yarrison, PhD and Lauren Dickey, BA University of Kentucky College of Medicine and Department of Philosophy Lexington, KY
Non-adherence to treatment plans is a common challenge for both patients and health care professionals. However, some cases that are described as non-adherence are more accurately described as cases of selective adherence. Selective adherence may involve "line-item refusals," in which a patient accepts a treatment plan generally but refuses specific elements, or "a la carte selections" in which the patient requests elements from different proposed plans that, when combined, are medically incoherent or unlikely to accomplish the goals of treatment. Establishing a medically coherent plan that also satisfies patient preferences can pose serious practical and ethical problems. Providers commonly find themselves in the ethical gray area of how to proceed when patients seek to select elements of their treatment plans without regard to the impact those choices may have on efficacy. These choices create tension between patients' right to refuse treatment and make their own medical decisions on the one hand, and providers' professional obligation to provide the standard of care and effective treatment on the other. This presentation will provide examples of selective adherence and address philosophical questions about autonomy and medical coherence. Strategies for resolving cases include identifying three questions that will help determine if the patient’s selections can reasonably be accommodated and, second, offering treatment plans as prix fixe instead of a la carte in cases in which the patient’s selections cannot be incorporated into a medically coherent plan of care with a favorable risk-benefit analysis. Ethical Considerations for Research Involving Adolescent Social Media Usage
Jamie Zelazny, PhD, RN University of Pittsburgh Pittsburgh, PA
Social media provides a window into the mental health of adolescents. Interpersonal relationships, bullying, and social connectedness are just a few examples of behaviors that can be explored on social media. Natural language processing and machine learning techniques are now being used evaluate social media posts by identifying words associated with suicidal risk. However, many ethical issues must be considered before undertaking this type of research. Using a case study approach, I will illustrate ethical issues that we are currently facing in our research of adolescent social media usage and will suggest potential protections against risk. First, I will address issues surrounding informed consent. In the state of Pennsylvania, children age 14 and older are legally able to consent for their own mental health treatment. Is it appropriate to waive parental permission for this type of research? Is child assent sufficient? Next, I will address ethical concerns about accessing social media in mental health research with teens. How should information posted by social media "friends" who have not consented to participate in research be handled? How should photographs be handled? Finally, I will discuss reporting issues. Should any information be reported back to parents? What information should be reported to therapists? Mandated reporter laws address the need to report imminent danger to self or others and child abuse, but what about risky behaviors that fall into more "gray" areas, such as alcohol and substance use, bullying, and “sexting” behavior?