unit 1 ■ Professionalism
Doctors at the Massachusetts General Hospital
for Children faced an ethical challenge when a
pair of conjoined twins born in Africa arrived
last year seeking surgery that could save only
one of them. The twins were connected at the
abdomen and pelvis, sharing a liver and bladder,
and had three legs. An examination by doctors
at the hospital determined that only one of the
girls was likely to survive the surgery, but that
if doctors did not act, both would die. The case
had posed the hospital with the challenge both
of ensuring that the parents understood the
risks of the procedure and that the hundreds
of medical professionals needed to perform
the complex series of operations to separate
the children were comfortable with the ethics
of the situation (Malone, 2017). Which child
should live, and which child should die?
This is only one of many modern ethical dilemmas faced by health-care personnel. If you were
a member of the ethics committee, what decision
might you make? How would you come to that
decision? Which twin would live and which would
In previous centuries, health-care practitioners
had neither the knowledge nor the technology to
make determinations regarding prolonging life,
sustaining life, or even creating life. The main
function of nurses and physicians was to support
patients and families through times of illness, help
them toward recovery, or provide comfort until
death. There were very few complicated decisions
such as “Who shall live and who shall die?” During
the latter part of the 20th century and through the
first part of the 21st century, technological advances
such as multiple-organ transplantation, use of stem
cells, new biologically based pharmaceuticals, and
sophisticated life-support systems created unique
situations stimulating serious conversations and
debates. The costs of these life-saving treatments
and technologies presented new dilemmas as to
who should provide and pay for them, as well as
who should receive them.
Health care saw its first technological advances
during 1947 and 1948 as the polio epidemic raged
through Europe and the United States. This devastating disease initiated the development of units
for patients who required manual ventilation (the
“iron lung”). During this period, Danish physicians invented a method of manual ventilation by
placing a tube into the trachea of polio patients.
This initiated the creation of mechanical ventilation as we know it today. The development of
mechanical ventilation required more intensive
nursing care and patient observation. The care and
monitoring of patients proved to be more efficient
when nurses kept patients in a single care area,
hence the term intensive care.
The late 1960s brought greater technological
advances. Open heart surgery, in its infancy at the
time, became available for patients who were seriously ill with cardiovascular disease. These patients
required specialized nursing care and nurses
specifically educated in the use of advancing technologies. These new therapies and monitoring
methods provided the impetus for the creation of
intensive care units and the critical care nursing
specialty ( Vincent, 2013).
In the past, the vast majority of individuals
receiving critical care services would have died.
However, the development of new drugs and
advances in biomechanical technology permit
health-care personnel to challenge nature. These
advances have enabled providers to offer patients
treatments that in many cases increase their
life expectancy and enhance their quality of life.
However, this progress is not without its shortcomings as it also presents new perplexing questions.
The ability to prolong life has created some
heart-wrenching situations for families and
complex ethical dilemmas for health-care professionals. Decisions regarding terminating life
support on an adolescent involved in a motor
vehicle accident, instituting life support on a
65-year-old productive father, or a mother becoming pregnant in order to provide stem cells for
her older child who has a terminally ill disease
are just a few examples. At what point do parents
say good-bye to their neonate who was born far
too early to survive outside the womb? Families
and professionals face some of the most difficult
ethical decisions at times such as these. How is
death defined? When does it occur? Perhaps these
questions need to be asked: “What is life? Is there
a difference between life and living?”
To find answers to these questions, health-care
professionals look to philosophy, especially the
branch that deals with human behavior. Through
time, to assist in dealing with these issues, the field
chapter 2 ■ Professional Ethics and Values
of biomedical ethics (or simply bioethics) evolved.
This subdiscipline of ethics, the philosophical
study of morality, is the study of medical morality,
which concerns the moral and social implications
of health care and science in human life (Numminen, Repo, & Leino-Kilpi, 2017).
In order to understand biomedical ethics, it
is important to appreciate the basic concepts
of values, belief systems, ethical theories, and
morality. The following sections will define these
concepts and then discuss ways nurses can help the
interprofessional team and families resolve ethical
Way, 2018). Reasoning allows individuals to think
for themselves and not to take the beliefs and
judgments of others at face value. Moral reasoning
relates to the process of forming conclusions and
creating action plans centered on moral or ethical
Values, viewpoints, and methods of moral
reasoning have developed through time. Older
worldviews have now emerged in modern history,
such as the emphasis on virtue ethics or a focus on
what type of person one would prefer to become
(McLeod-Sordjan, 2014). Virtue ethics are discussed later in this chapter.
Individuals talk about value and values all the
time. The term value refers to the worth of an
object or thing. However, the term values refers
to how individuals feel about ideas, situations,
and concepts. Merriam-Webster’s Collegiate Dictionary defines value as the “estimated or appraised
worth of something, or that quality of a thing that
makes it more or less desirable, useful” (MerriamWebster Dictionary, 2017). Values, then, are judgments about the importance or unimportance of
objects, ideas, attitudes, and attributes. Individuals
incorporate values as part of their conscience and
worldview. Values provide a frame of reference and
act as pilots to guide behaviors and assist people in
Morals arise from an individual’s conscience. They
act as a guide for individual behavior and are
learned through family systems, instruction, and
socialization. Morals find their basis within individual values and have a larger social component
than values (Ma, 2013). They focus more on “good”
versus “bad” behaviors. For example, if you value
fairness and integrity, then your morals include
those values, and you judge others based on your
concept of morality (Maxwell & Narvaez, 2013).
Values and Moral Reasoning
Reasoning is the process of making inferences
from a body of information and entails forming
conclusions, making judgments, or making
inferences from knowledge for the purpose of
answering questions, solving problems, and formulating a plan that determines actions (McHugh &
A value system is a set of related values. For
example, one person may value (believe to be
important) societal aspects of life, such as money,
objects, and status. Another person may value
more abstract concepts such as kindness, charity,
and caring. Values may vary significantly, based on
an individual’s culture, family teachings, and religious upbringing. An individual’s system of values
frequently affects how he or she makes decisions.
For example, one person may base a decision on
cost, whereas another person placed in the same
situation may base the decision on a more abstract
quality, such as kindness. Values fall into different
Intrinsic values are those related to sustaining
life, such as food and water (Zimmerman &
■ Extrinsic values are not essential to life. They
include the value of objects, both physical
and abstract. Extrinsic values are not an end
in themselves but offer a means of achieving
something else. Things, people, and material
items are extrinsically valuable (Zimmerman &
■ Personal values are qualities that people
consider important in their private lives.
Concepts such as strong family ties and
acceptance by others are personal values.
■ Professional values are qualities considered
important by a professional group. Autonomy,
integrity, and commitment are examples of
People’s behaviors are motivated by values. Individuals take risks, relinquish their own comfort
and security, and generate extraordinary efforts
unit 1 ■ Professionalism
because of their values (Zimmerman & Zalta,
2014). Patients who have traumatic brain injuries
may overcome tremendous barriers because they
value independence. Race car drivers may risk
death or other serious injury because they value
competition and winning.
Values also generate the standards by which
people judge others. For example, someone who
values work more than leisure activities will look
unfavorably on a coworker who refuses to work
throughout the weekend. A person who believes
that health is more important than wealth would
approve of spending money on a relaxing vacation
or perhaps joining a health club rather than investing the money.
Often people adopt the values of individuals they admire. For example, a nursing student
may begin to value humor after observing it used
effectively with patients. Values provide a guide
for decision making and give additional meaning
to life. Individuals develop a sense of satisfaction
when they work toward achieving values they
believe are important (Tuckett, 2015).
How Values Are Developed
Values are learned (Taylor, 2012). Ethicists attribute the basic question of whether values are
taught, inherited, or passed on by some other
mechanism to Plato, who lived more than
2,000 years ago. A recent theory suggests that
values and moral knowledge are acquired much
in the same manner as other forms of knowledge,
through real-world experience.
Values can be taught directly, incorporated
through societal norms, and modeled through
behavior. Children learn by watching their parents,
friends, teachers, and religious leaders. Through
continuous reinforcement, children eventually
learn about and then adopt values as their own.
Because of the values they hold dear, people often
make great demands on themselves and others,
ignoring the personal cost. For example:
Niesa grew up in a family where educational
achievement was highly valued. Not surprisingly, she adopted this as one of her own values.
Niesa became a physician, married, and had
a son, Dino. She placed a great deal of effort
on teaching her son the necessary educational
skills in order to get him into the “best private
school” in the area. As he moved through the
program, his grades did not reflect his mother’s
great effort, and he felt that he had disappointed his mother as well as himself. By the
time Dino reached 9 years of age, he had developed a variety of somatic complaints such as
stomach ailments and headaches.
Values change with experience and maturity.
For example, young children often value objects,
such as a favorite blanket or toy. Older children
are more likely to value a specific event, such as
a family vacation. As children enter adolescence,
they place more value on peer opinions than those
of their parents. Young adults often place value on
certain ideals such as heroism. The values of adults
are formed from all these experiences as well as
from learning and thought.
The number of values that people hold is not as
important as what values they consider important.
Choices are influenced by values. The way people
use their own time and money, choose friends, and
pursue a career are all influenced by values.
Values clarification is deciding what one believes
is important. It is the process that helps people
become aware of their values. Values play an
important role in everyday decision making. For
this reason, nurses need to be aware of what they
do and do not value. This process helps them to
behave in a manner that is consistent with their
Both personal and professional values influence nurses’ decisions (McLeod-Sordjan, 2014).
Understanding one’s own values simplifies solving
problems, making decisions, and developing better
relationships with others when one begins to
realize how others develop their values. Kirschenbaum (2011) suggested using a three-step model
of choosing, prizing, and acting with seven substeps to identify one’s own values (Box 2-1).
You may have used this method when making
the decision to go to nursing school. For some
people, nursing is a first career; for others, a second
career. Using the model in Box 2-1, the valuing
process is analyzed:
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1. Choosing freely
2. Choosing from alternatives
3. Deciding after giving consideration to the
consequences of each alternative
4. Being satisfied about the choice
5. Being willing to declare the choice to others
6. Making the choice a part of one’s worldview and
incorporating it into behavior
7. Repeating the choice
Source: Adapted from Raths, L. E., Harmon, M., & Simmons, S. B.
(1979). Values and teaching. New York, NY: Charles E. Merrill.
1. Choosing After researching alternative career
options, you freely choose nursing school. This
choice was most likely influenced by such
factors as educational achievement and abilities,
finances, support and encouragement from
others, time, and feelings about people.
2. Prizing Once the choice was made, you were
satisfied with it and told your friends about it.
3. Acting You entered school and started the
journey toward your new career. Later in your
career, you may decide to return to school for a
bachelor’s or master’s degree in nursing.
As you progressed through school, you probably started to develop a new set of values—your
professional values. Professional values are those
established as being important in your practice.
The values include caring, quality of care, and
ethical behaviors (McLeod-Sordjan, 2014).
Belief systems are an organized way of thinking about why people exist in the universe. The
purpose of belief systems is to explain issues such
as life and death, good and evil, and health and
illness. Usually these systems include an ethical
code that specifies appropriate behaviors. People
may have a personal belief system, participate in
a religion that provides such a system, or follow a
combination of the two.
Members of primitive societies worshipped
events in nature. Unable to understand the science
of weather, for example, early civilizations believed
these events to be under the control of someone
or something that needed to be appeased. Therefore, they developed rituals and ceremonies to
pacify these unknown entities. They called these
entities “gods” and believed that certain behaviors
either pleased or angered the gods. Because these
societies associated certain behaviors with specific
outcomes, they created a belief system that enabled
them to function as a group.
As higher civilizations evolved, belief systems
became more complex. Archeology has provided
evidence of the religious practices of ancient civilizations that support the evolution of belief
systems (Ball, 2015). The Aztec, Mayan, Incan,
and Polynesian cultures had a religious belief
system composed of many gods and goddesses for
the same functions. The Greek, Roman, Egyptian,
and Scandinavian societies believed in a hierarchal
system of gods and goddesses. Although given
various names by the different cultures, it is very
interesting that most of the deities had similar
purposes. For example, the Greeks looked at Zeus
as the king of the Greek gods, whereas Jupiter was
his Roman counterpart. Thor was the king of the
Norse gods. All three used a thunderbolt as their
symbol. Sociologists believe that these religions
developed to explain what was then unexplainable.
Human beings have a deep need to create order
from chaos and to have logical explanations for
events. Religion offers theological explanations to
answer questions that cannot be explained by “pure
Along with the creation of rites and rituals, religions also developed codes of behaviors or ethical
codes. These codes contribute to the social order
and provide rules regarding how to treat family
members, neighbors, and the young and the old.
Many religions also developed rules regarding
marriage, sexual practices, business practices, property ownership, and inheritance.
For some individuals, the advancement of
science has minimized their need for belief
systems, as science can now provide explanations
for many previously unexplainable phenomena.
In fact, the technology explosion has created an
even greater need for belief systems. Technological advances often place people in situations where
they may welcome rather than oppose religious
convictions to guide difficult decisions. Many religions, particularly Christianity, focus on the will of
unit 1 ■ Professionalism
a supreme being; technology, for example, is considered a gift that allows health-care personnel to
maintain the life of a loved one. Other religions,
such as certain branches of Judaism, focus on free
choice or free will, leaving such decisions in the
hands of humankind. For example, many Jewish
leaders believe that if genetic testing indicates
that an infant will be born with a disease such as
Tay-Sachs that causes severe suffering and ultimately death, terminating the pregnancy may be
an acceptable option.
Belief systems often help survivors in making
decisions and living with them afterward. So far,
technological advances have created more questions than answers. As science explains more and
more previously unexplainable phenomena, people
need beliefs and values to guide their use of this
Although the terms morals and ethics are often used
interchangeably, ethics usually refers to a standardized code as a guide to behaviors, whereas morals
usually refers to an individual’s personal code for
Teleological theories take their norms or rules
for behaviors from the consequences of the action.
This theory is also called utilitarianism. According to this concept, what makes an action right
or wrong is its utility, or usefulness. Usefulness is
considered to be the right amount of “happiness”
the action carries. “Right” encompasses actions
that result in good outcomes, whereas “wrong”
actions end in bad outcomes. This theory originated with David Hume, a Scottish philosopher.
According to Hume, “Reason is and ought to be
the slave of passions” (Hume, 1978, p. 212). Based
on this idea, ethics depends on what people want
and desire. The passions determine what is right
or wrong. However, individuals who follow teleological theory disagree on how to decide on the
“rightness” or “wrongness” of an action because
individual passions differ.
Principalism is an arising theory receiving a
great deal of attention in the biomedical ethics
community. This theory integrates existing ethical
principles and tries to resolve conflicts by relating
one or more of these principles to a given situation
(Hine, 2011; Varelius, 2013). Ethical principles
actually influence professional decision making
more than ethical theories.
Ethics is the part of philosophy that deals with
the rightness or wrongness of human behavior.
It is also concerned with the motives behind that
behavior. Bioethics, specifically, is the application of
ethics to issues that pertain to life and death. The
implication is that judgments can be made about
the rightness or goodness of health-care practices.
Ethical codes are based on principles that can be
used to judge behavior. Ethical principles assist
decision making because they are a standard for
measuring actions. They may be the basis for laws,
but they themselves are not laws. Laws are rules
created by governing bodies. Laws operate because
the government holds the power to enforce them.
They are usually quite specific, as are the consequences for disobeying them. Ethical principles
are not confined to specific behaviors. They act as
guides for appropriate behaviors. They also consider the situation in which a decision must be
made. Ethical principles speak to the essence of
the law rather than to the exactness of the law.
Here is an example:
Ethics and Morals
Several ethical theories have emerged to justify
moral principles (Baumane-Vitolina, Cals, &
Sumilo, 2016). Deontological theories take their
norms and rules from the duties that individuals
owe each other by the goodness of the commitments they make and the roles they take upon
themselves. The term deontological comes from the
Greek word deon (duty). This theory is attributed
to the 18th-century philosopher Immanuel Kant
(Kant, 1949). Deontological ethics considers the
intention of the action. In other words, it is the
individual’s good intentions or goodwill (Kant,
1949) that determines the worthiness or goodness
of the action.
Mrs. Gustav, 88 years old, was admitted to the
hospital in acute respiratory distress. She was
diagnosed with aspiration pneumonia and soon
became septic, developing acute respiratory distress syndrome (ARDS). She had a living will,
and her attorney was her designated health-care
chapter 2 ■ Professional Ethics and Values
surrogate. Her competence to make decisions
remained uncertain because of her illness. The
physician presented the situation to the attorney, indicating that without a feeding tube and
tracheostomy, Mrs. Gustav would die. According to the laws governing living wills and
health-care surrogates, the attorney could have
made the decision to withhold all treatments.
However, he believed he had an ethical obligation to discuss the situation with his client. The
client requested the tracheostomy be performed
and the feeding tube inserted, which was done.
Following are several of the ethical principles that
are most important to nursing practice: autonomy,
nonmaleficence, beneficence, justice, fidelity, confidentiality, veracity, and accountability. In some
situations, two or more ethical principles may conflict with each other, leading to an ethical dilemma.
Making a decision under these circumstances
causes difficulty and often results in extreme stress
for those who need to make the decision.
Autonomy is the freedom to make decisions for
oneself. This ethical principle requires that nurses
respect patients’ rights to make their own choices
about treatments. Informed consent before treatment, surgery, or participation in research provides
an example of autonomy. To be able to make
an autonomous choice, individuals need to be
informed of the purpose, benefits, and risks of the
procedures. Nurses accomplish this by assessing
the individuals’ understanding of the information
provided to them and supporting their choices.
Closely linked to the ethical principle of autonomy is the legal issue of competence. A patient
needs to be deemed competent in order to make
a decision regarding treatment options. When
patients refuse treatment, health-care personnel
and family members who think differently often
question the patient ’s “competence” to make a
decision. Of note is the fact that when patients
agree with health providers’ treatment decisions,
rarely is their competence questioned (Shahriari,
Mohammadi, Abbaszadeh, & Bahrami, 2013).
Nurses often find themselves in a position to
protect a patient ’s autonomy. They do this by preventing others from interfering with the patient ’s
right to proceed with a decision. If a nurse observes
that a patient received insufficient information to
make an appropriate choice, is being coerced into
a decision, or lacks an understanding of the consequences of the choice, then the nurse may act as a
patient advocate to ensure the principle of autonomy (Rahmani, Ghahramanian, & Alahbakhshian,
Sometimes nurses have difficulty with the
principle of autonomy because it also requires
respecting another person’s choice, even when
the nurse disagrees. According to the principle
of autonomy, nurses may not replace a patient ’s
decision with their own, even when the nurses
deeply believe that the patient made the wrong
choice. Nurses may, however, discuss concerns
with patients and ensure that patients considered
the consequences of the decision before making it
(Rahmani et al., 2010).
The ethical principle of nonmaleficence requires
that no harm be done, either deliberately or unintentionally. This rather complicated word comes
from Latin roots, non, which means not; male
(pronounced mah-leh), which means bad; and
facere, which means to do.
The principle of nonmaleficence also requires
nurses to protect individuals who lack the ability
to protect themselves because of their physical
or mental condition. An infant, a person under
anesthesia, and a person suffering from dementia
are examples of individuals with limited ability to
protect themselves from danger or those who may
cause them harm. Nurses are ethically obligated to
protect their patients when the patients are unable
to protect themselves.
Often, treatments meant to improve patient
health lead to harm. This is not the intention of the
nurse or of other health-care personnel, but it is a
direct result of treatment. Nosocomial infections
because of hospitalization are harmful to patients.
The nurses, however, did not deliberately cause the
infection. The side effects of chemotherapy or radiation may also result in harm. Chemotherapeutic
agents cause a decrease in immunity that may
result in a severe infection, and radiation may burn
or damage the skin. For this reason, many choose
not to pursue treatments.
The obligation to do no harm extends to the
nurse who for some reason is not functioning at an
optimal level. For example, a nurse who is impaired
unit 1 ■ Professionalism
by alcohol or drugs knowingly places patients at
risk. According to the principle of nonmaleficence,
other nurses who observe such behavior have an
ethical obligation to protect patients.
The word beneficence also comes from Latin: bene,
which means well, and facere, which means to do.
The principle of beneficence demands that good
be done for the benefit of others. For nurses, this
means more than delivering competent physical
or technical care. It requires helping patients meet
all their needs, whether physical, social, or emotional. Beneficence is caring in the truest sense,
and caring fuses thought, feeling, and action. It
requires knowing and being truly understanding
of the situation and the thoughts and ideas of the
individual (Benner & Wruble, 1989).
Sometimes physicians, nurses, and families
withhold information from patients for the sake
of beneficence. The problem with doing this is that
it does not allow competent individuals to make
their own decisions based on all available information. In an attempt to be beneficent, the principle
of autonomy is violated. This is just one example of
the ethical dilemmas encountered in nursing practice. For instance:
Mrs. Liu was admitted to the oncology unit
with ovarian cancer. She is scheduled to begin
chemotherapy treatments. Her two children and
her husband have requested that the physician
ensure that Mrs. Liu not be told her diagnosis
because they believe she would not be able to
cope with it. The physician communicated this
information to the nursing staff and placed an
order in the patient ’s electronic medical record
(EMR). After the first treatment, Mrs. Liu
became very ill. She refused the next treatment,
stating she did not feel sick until she came to
the hospital. She asked the nurse what could
possibly be wrong with her that she needed a
medicine that made her sick when she did not
feel sick before. She then said, “Only people
who get cancer medicine get this sick! Do I
As the nurse, you understand the order that
the patient not be told her diagnosis. You also
understand your role as a patient advocate. Consider the following questions:
1. To whom do you owe your duty: to the patient
or the family?
2. How do you think you may be able to be a
patient advocate in this situation?
3. What information would you communicate to
the family members, and how could you assist
them in dealing with their mother’s concerns?
The principle of justice obliges nurses and other
health-care professionals to treat every person
equally regardless of gender, sexual orientation,
religion, ethnicity, disease, or social standing ( Johnstone, 2011). This principle also applies in the work
and educational settings. Based on this principle,
all individuals should be treated and judged by the
same criteria. The following example illustrates this:
Mr. Laury was found on the street by the
police, who brought him to the emergency
department. He was assessed and admitted to a
medical unit. Mr. Laury was in deplorable condition: His clothes were dirty and ragged, he
was unshaven, and he was covered with blood.
His diagnosis was chronic alcoholism, complicated by esophageal varices and end-stage liver
disease. Several nursing students overheard the
staff discussing Mr. Laury. The essence of the
conversation was that no one wanted to care for
him because he was “dirty and smelly,” and he
brought this condition on himself. The students,
upset by what they heard, went to the clinical
faculty to discuss the situation. The clinical
faculty explained that based on the ethical principle of justice, every individual has a right to
good care despite his or her economic or social
The concept of distributive justice necessitates
the fair allocation of responsibilities and advantages, especially in a society where resources may
be limited. Considered an ethical principle, distributive justice refers to what society, or a larger
group, feels is indebted to its individual members
regarding: (1) individual needs, contributions, and
chapter 2 ■ Professional Ethics and Values
responsibilities; (2) the resources available to the
society or organization; and (3) the society ’s or
organization’s responsibility to the common good
(Capp, Savage, & Clarke, 2001). Increased healthcare costs through the years and access to care
have become social and political issues. In order
to understand distributive justice, we must address
the concepts of need, individual effort, ability to
pay, contribution to society, and age (Zahedi et al.,
Age has become a controversial issue as it
leads to questions pertaining to quality of life
(Skedgel, Wailoo, & Akehurst, 2015). The other
issue regarding age revolves around technology in
neonatal care. How do health-care providers place
a value on one person’s life being higher than that
of another? Should millions of dollars be spent
preserving the life of an 80-year-old man who volunteers in his community, plays golf twice a week,
and teaches reading to underprivileged children,
or should money be spent on a 26-week-old fetus
that will most likely require intensive therapies and
treatments for a lifetime, adding up to millions
of health-care dollars? In the social and business
world, welfare payments are based on need, and
jobs and promotions are usually distributed on the
basis of an individual’s contributions and achievements. Is it possible to apply these measures to
Philosopher John Rawls addressed the issues
of fairness and justice as the foundation of
social structures (Ekmekci & Arda, 2015). Rawls
addresses the issue of fair distribution of social
goods using the idea of the original position to
negotiate the principles of justice. The original
position based on Kant ’s (1949) social contract
theory presents a hypothetical situation where
individuals, known as negotiators, act as trustees
for the interests of all individuals. These individuals are knowledgeable in the areas of sociology,
political science, and economics. However, this
position places certain limitations on them known
as the veil of ignorance, which eliminates information about age, gender, socioeconomic status, and
religious convictions. With the absence of this
information, the vested interests of all parties disappear. According to Rawls, in a just society the
rights protected by justice are not political bargaining issues or subject to the calculations of
social interests. Simply put, everyone has the same
rights and liberties (Ekmekci & Arda, 2015).
The principle of fidelity requires loyalty. It is a
promise that the individual will fulfill all commitments made to himself or herself and to others. For
nurses, fidelity includes the professional’s loyalty to
fulfill all responsibilities and agreements expected
as part of professional practice. Fidelity is the basis
for the concept of accountability—taking responsibility for one’s own actions (Ostlund, Backstrom,
Lindh, Sundin, & Saveman, 2015).
The principle of confidentiality states that anything patients say to nurses and other health-care
providers must be held in the strictest confidence.
Confidentiality presents both an ethical and legal
issue. Exceptions only exist when patients give
permission for the sharing of information or when
the law requires the release of specific information.
Sometimes simply sharing information without
revealing an individual’s name can be a breach of
confidentiality if the situation and the individual
Nurses come into contact with people from
all walks of life. Within communities, individuals
know other individuals who know others, creating
“micro-communities” of information. Individuals have lost families, employment, and insurance
coverage because nurses shared confidential information and others acted on that knowledge
(Beltran-Aroca, Girela-Lopez, Collazo-Chao,
Montero-Pérez-Barquero, & Muñoz-Villanueva,
In today ’s electronic environment, the principle of confidentiality has become a major concern,
especially in light of the security breaches that have
occurred throughout the last several years. Many
health-care institutions, insurance companies, and
businesses use electronic media to transfer sensitive and confidential information, allowing more
opportunities for a breakdown in confidentiality. Health-care institutions and providers have
attempted to address the situation through the
use of passwords, limited access, and cybersecurity.
However, it has become more apparent that the
securest of systems remain vulnerable to hacking
and illegal access.
Veracity requires nurses to be truthful. Truth is
fundamental to building a trusting relationship.
unit 1 ■ Professionalism
Intentionally deceiving or misleading a patient is a
violation of this principle. Deliberately omitting a
part of the truth is deception and violates the principle of veracity. This principle often creates ethical
dilemmas. When is it permissible to lie? Some
ethicists believe it is never appropriate to deceive
another individual. Others think that if another
ethical principle overrides veracity, then lying is
acceptable (Sokol, 2007). Consider this situation:
Ms. Allen has been told that her father suffers
from Alzheimer’s disease. The nurse practitioner
wants to come into the home to discuss treatment options. Ms. Allen refuses, explaining that
under no circumstances should the nurse practitioner tell her father the diagnosis. Ms. Allen
bases her concern on past statements made by
her father. She explains to the nurse practitioner that if her father finds out his diagnosis,
he will take his own life. The nurse practitioner
provides information on the newest treatments
and available medications that might help.
However, these treatments and medications
are only available through a research study. To
participate in the study, the patient needs to be
aware of the benefits and the risks. Ms. Allen
continues refusing to allow anyone to tell her
father his diagnosis because of her certainty
that he will commit suicide.
The nurse practitioner faces a dilemma: Does he
abide by Ms. Allen’s wishes based on the principle
of beneficence, or does he abide by the principle
of veracity and inform his patient of the diagnosis? If he goes against Ms. Allen’s wishes and tells
the patient his diagnosis, and he commits suicide,
has nonmaleficence been violated? Did the practitioner’s action cause harm? What would you do in
Accountability is linked to fidelity and means
accepting responsibility for one’s own actions.
Nurses are accountable to their patients and to their
colleagues. When providing care to patients, nurses
are responsible for their actions, good and poor. If
something was not done, do not chart it and tell
a colleague that it was completed. An example of
violating accountability is the story of Anna:
Anna was a registered nurse who worked
nights on an acute care medical unit. She was
an excellent nurse; however, as the acuity of the
patients’ conditions increased, she was unable to
keep up with both patients’ needs and the technology, particularly intravenous fluids and lines.
The pumps confused her, so often she would
take the fluids off the pump and “monitor her
IVs” the way she did in the past. She started to
document that all the IVs were infusing as they
should, even when they were not. Each morning
the day shift would find that the actual infused
amount did not agree with the documentation, even though “pumps” were found for each
patient. One night, Anna allowed an entire liter
of intravenous fluids to be infused in 2 hours
into a patient who had heart failure. When the
day staff came on duty, they found the patient
expired, the bag empty, and the tubing filled
with blood. The IV was attached to the pump.
Anna’s documentation showed 800 mLs left
in the bag. It was not until after a lawsuit was
filed that Anna assumed responsibility for her
The idea of a standard of care evolves from the
principle of accountability. Standards of care
provide a rule for measuring nursing actions and
safety issues. According to the Institute of Medicine (IOM), organizations also hold accountability
for patient care and the actions of personnel. Based
on the Institute for Healthcare Improvement
(IHI), health-care organizations have a duty to
ensure a safe environment and that all personnel
receive appropriate training and education (IHI,
A code of ethics is a formal statement of the rules
of ethical behavior for a particular group of individuals. A code of ethics is one of the hallmarks of
a profession. This code makes clear the behavior
expected of its members.
The American Nurses Association (ANA) Code
of Ethics for Nurses With Interpretive Statements
(Olsen & Stokes, 2016) provides values, standards,
and principles to help nursing function as a profession. The ANA developed the original code in
1985; it has gone through several revisions during
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the years since its development and may be viewed
online at www.nursingworld.org.
Ethical codes remain subject to change. They
reflect the values of the profession and the society
for which they were developed. Changes occur as
society and technology evolve. For example, years
ago no thought was given to Do Not Resuscitate
(DNR) orders or withholding food or fluids. Technological advances have since made it possible to
keep people in a type of twilight life, comatose
and unable to participate in living in any way, thus
making DNR and withholding very important
issues in health care. Technology and scientific
advancements increased knowledge and skills, but
the ability to make decisions regarding care continues to be guided by ethical principles.
Virtue ethics focuses on virtues or moral character,
rather than on duties or rules that emphasize consequences of actions. Consider the following:
Carlos is driving along the highway and discovers a crying child sitting by a fallen bicycle. It
is obvious that the child needs assistance. From
one ethical standpoint (utilitarianism), helping
the child will increase Carlos’s feelings of “doing
good.” The deontological stance states that by
helping, Carlos is behaving in accordance with a
moral rule such as “Do unto others. . . .” Virtue
ethics looks at the fact that, by helping, Carlos
would be acting charitable or benevolent.
Plato and Aristotle are considered the founders
of virtue ethics. Its roots can be found in Chinese
philosophy. During the 1800s, virtue ethics disappeared, but in the late 1950s it re-emerged as an
Anglo-American philosophy. Neither deontology
nor utilitarianism considered the virtues of moral
character and education and the question: “What
type of person should I be, and how should I live”
(Sakellariouv, 2015). Virtues include qualities such
as honesty, generosity, altruism, and reliability.
They are concerned with many other elements as
well, such as emotions and emotional reactions,
choices, values, needs, insights, attitudes, interests,
and expectations. Nursing has practiced virtue
ethics for many years.
Up to this point, the ethical principles discussed
apply to ethics for nurses; however, nurses do not
customarily find themselves enmeshed in the biomedical ethical decision-making processes that
gain attention. The ethical principles that guide
nursing practice are rooted in the philosophy and
science of health care.
Relationships are the center of nursing ethics.
Nursing ethics, viewed from the perspective of
nursing theory and practice, deals with the experiences and needs of nurses and their perceptions of
these experiences ( Johnstone, 2011).
Organizational ethics focus on the workplace at
the organizational level. Every organization, even
one with hundreds of thousands of employees,
consists of individuals. Each individual makes his
or her own decisions about how to behave in the
workplace (Carucci, 2016), and every person has
the opportunity to make an organization a more
or less ethical place. These individual decisions
exert a powerful effect on the lives of many others
in the organization as well as the surrounding
Most organizations create a set of values that
guide the organizational ideals, practices, and
expectations (Leonard, 2018). Although given
varying “names,” such as core values, practice
values, and so on, they lay the groundwork for
expectations for employees. What is most important is that employees see that the organization
practices what it states. Leadership, especially
senior leadership, is the most critical factor in promoting an ethical culture.
When looking for a professional position, it is
important to consider the organizational culture
and ethical guides. What are the values and beliefs
of the organization? Do they blend with yours,
or are they in conflict with your value system? To
discover this information, look at the organization’s mission, vision, and value statements. Speak
with other nurses who work in the organization.
Do they see consistency between what the organization states and what it actually expects from
employees? For example, if an organization states
that it collaborates with the nurses in decision
making, do nurses sit on committees that provide
input toward the decision-making process (Choi,
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Jang, Park, & Lee, 2014)? Conflicts between a
nurse’s professional values and those of the organization result in moral distress for the nurse.
Ethical Issues on the Nursing Unit
Organizational ethics refer to the values and
expected behaviors entrenched within the organizational culture. The nursing unit represents
a subculture within a health-care organization.
Ideally, the nursing unit should mirror the ethical
atmosphere and culture of the organization. This
requires the individuals who staff the unit to
embrace the same values and model the expected
behaviors (Choi et al., 2014).
Conflicts with the values and ethics among
individuals who work together on a unit often
create issues that result in moral suffering for some
nurses. Moral suffering occurs when nurses experience a feeling of uneasiness or concern regarding
behaviors or circumstances that challenge their
own morals and beliefs (Epstein & Hamric, 2009;
Morley, 2016). These situations may be the result
of unit policies, physician’s orders that the nurse
believes may not be beneficial for the patient,
professional behaviors of colleagues, or family attitudes about the patient (Morley, 2016).
Perhaps one of the most disconcerting ethical
issues nurses on the patient care unit face is the
one that challenges their professional values and
ethics. Friendships often emerge from work relationships, and these friendships may interfere with
judgments. Similarly, strong negative feelings may
cloud a nurse’s ability to view a situation fairly and
without prejudice. Consider the following:
Irina and James attended nursing school
together and developed a strong friendship.
They work together on the pediatric surgical
unit of a large teaching hospital. The hospital
provides full tuition reimbursement for graduate education, so both decided to return to
graduate school together and enrolled in a
nurse practitioner program. Irina made a medication error that she decided not to report, an
error that resulted in a child being transferred
to the pediatric intensive care unit. James realized what happened and confronted Irina, who
begged him not to say anything. James knew
the error needed to be reported, but how would
this affect his friendship with Irina? Taking this
situation to the other extreme, if a friendship
had not been involved, would James react the
same way? What would you do in this situation?
When working with others, it is important to
hold true to your personal values and moral standards. Practicing virtue ethics, that is, “doing the
right thing,” may cause difficulty because of the
possible consequences of the action. Nurses should
support each other, but not at the expense of
patients or each other’s professional duties. There
are times when not acting virtuously may cause a
colleague more harm.
Moral Distress in Nursing Practice
Moral distress occurs when nurses know the action
they need to take, but for some reason find themselves unable to act (Fourie, 2015). This is usually
the result of external forces or loyalties (Hamric,
2014). Therefore, the action or actions they take
create conflict as the decision goes against their
personal and professional values, morals, and
beliefs (Morley, 2016). These situations challenge
nurses’ integrity and authenticity.
Studies have shown that nurses exposed to
moral distress suffer from emotional and physical
problems and eventually leave the bedside and the
profession. Sources of moral distress vary; however,
contributing factors include end-of-life challenges,
nurse-physician conflicts, workplace bullying or
violence, and disrespectful interactions (Oh &
Gastmans, 2015). Nursing organizations such as
the American Association of Critical Care Nurses
(AACN, 2018) have developed guidelines addressing the issue of moral distress.
What is a dilemma? The word dilemma is of Greek
derivation. A lemma was an animal resembling a
ram and having two horns. Thus came the saying,
“stuck on the horns of a dilemma.” The story of
Hugo illustrates a hypothetical dilemma with a
touch of humor:
One day Hugo, dressed in a bright red cape,
walked through his village into the countryside.
chapter 2 ■ Professional Ethics and Values
The wind caught the corners of his cape, and it
was whipped in all directions. As he continued
down the dusty road, Hugo happened to pass
by a lemma. Hugo’s bright red cape caught the
lemma’s attention. Lowering its head, with its
two horns posed in attack position, the animal
started chasing Hugo down the road. Panting
and exhausted, Hugo reached the end of the
road only to find himself blocked by a huge
stone wall. He turned to face the lemma, which
was ready to charge. A decision needed to be
made, and Hugo’s life depended on this decision. If he moved to the left, the lemma would
gore his heart. If he moved to the right, the
lemma would gore his liver. No matter what his
decision, Hugo would be “stuck on the horns of
Similar to Hugo, nurses are often faced with
difficult dilemmas. Also, as Hugo found, a dilemma
can be a choice between two serious alternatives.
An ethical dilemma occurs when a problem exists
that forces a choice between two or more ethical
principles. Deciding in favor of one principle will
violate the other. Both sides have goodness and
badness to them; however, neither decision satisfies all the criteria that apply ( Jie, 2015).
Ethical dilemmas also carry the added burden
of emotions. Feelings of anger, frustration, and fear
often override rational decision making. Consider
the case of Mr. Rodney:
Mr. Rodney, 85 years old, was admitted to
the neuroscience unit after suffering a left
hemispheric bleed while playing golf with his
friends. He had a total right hemiplegia and
a Glasgow Coma Score of 8. He had been
receiving intravenous fluids for 4 days, and the
neurologist raised the question of placing a
jejunostomy tube for enteral feedings. The older
of his two children asked what the chances of
his recovery were. The neurologist explained
that Mr. Rodney ’s current state was probably the best he could attain but that “miracles
happen every day,” and that some diagnostic
tests might help in determining the prognosis. The family requested the tests. After the
results were available, the neurologist explained
that the prognosis remained grave and that the
intravenous fluids were insufficient to sustain
life. The jejunostomy tube would be a necessity if the family wished to continue with food
and fluids. After the neurologist left, the family
asked the nurse, Gloria, who had been caring
for Mr. Rodney during the previous 3 days, “If
this was your father, what would you do?” Once
the family asked Gloria this question, the situation became an ethical dilemma for her as well.
If you were Gloria, how might you respond?
Depending on your answer, what ethical principles
would be in conflict here?
Resolving Ethical Dilemmas
Faced by Nurses
Ethical dilemmas can occur in any aspect of life,
personal or professional. This section focuses on the
resolution of professional dilemmas. The various
models for resolving ethical dilemmas consist of
5 to 14 sequential steps. Each step begins with a
complete understanding of the dilemma and concludes with the evaluation of the implemented
The nursing process provides a helpful mechanism for finding solutions to ethical dilemmas. The
first step is assessment, including identification of
the problem. The simplest way to do this is to
create a statement that summarizes the issue. The
remainder of the process evolves from this statement (Box 2-2).
Ask yourself, “Am I directly involved in this
dilemma?” An issue is not an ethical dilemma
for nurses unless they find themselves directly
involved in the situation or have been asked for
their opinion. Some nurses involved themselves
Questions to Help Resolve Ethical Dilemmas
• What are the medical facts?
• What are the psychosocial facts?
• What are the patient’s wishes?
• What values are in conflict?
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in situations even when no one solicited their
opinion. This is generally unwarranted unless the
issue involves a violation of the professional code
Nurses are frequently in the position of hearing
both sides of an ethical dilemma. Often individuals only want an empathetic listener. At other
times, when guidance is requested, nurses can help
people work through the decision-making process
(remember the principle of autonomy) (Barlow,
Hargreaves, & Gillibrand, 2018).
Collecting data from all the decision makers
helps identify the reasoning process used by the
individuals as they struggle with the issue. The
following questions assist in the informationgathering process:
What are the medical facts? Find out how
the physicians, nurse practitioners, and all
members of the interprofessional health-care
team view the patient ’s condition and treatment
options. Speak with the patient if possible,
and determine his or her understanding of
■ What are the psychosocial facts? What is
the emotional state of the patient right now?
The patient ’s family? What kind of relationship
exists between the patient and his or her
family? What are the patient ’s living conditions?
Who are the individuals who form the patient ’s
support system? How are they involved in the
patient ’s care? What is the patient ’s ability
to make medical decisions about his or her
care? Do financial considerations need to be
taken into account? What does the patient
value? What does the patient ’s family value?
The answers to these questions will provide a
better understanding of the situation. Ask more
questions, if necessary, to complete the picture.
The social facts of a situation also include
the institutional policies, legal aspects, and
economic factors. The personal belief systems of
the providers may also influence this aspect.
■ What are the cultural beliefs? Cultural beliefs
play a major role in ethical decisions. Some
cultures do not allow surgical interventions as
they fear that the “life force” may escape. Many
cultures forbid organ donation. Other cultures
focus on the sanctity of life, thereby requesting
that providers use all available methods for
What are the patient’s wishes? Remember
the ethical principle of autonomy? With very
few exceptions, if the patient is competent, his
or her decisions take precedence. Too often,
the family ’s or provider’s worldview and belief
system overshadow those of the patient. Nurses
can assist by maintaining the focus on the
patient. If the patient is unable to communicate,
try to discover if the individual discussed the
issue in the past. If the patient completed a
living will or advance directives and designated
a health-care surrogate, this helps determine
the patient ’s wishes. By interviewing family
members, the nurse can often learn about
conversations where the patient voiced his or
her feelings about treatment decisions. Using
guided interviewing, the nurse can encourage
the family to share anecdotes that provide
relevant insights into the patient ’s values and
■ What values are in conflict? To assess values,
begin by listing each person involved in the
situation. Then identify values represented by
each person. Ask such questions as, “What do
you feel is the most pressing issue here?” and
“Tell me more about your feelings regarding
this situation.” In some cases, there may be little
disagreement among the people involved, just
a different way of expressing individual beliefs.
However, in others, a serious value conflict may
For planning to be successful, everyone involved
in the decision must be included in the process.
Thompson and Thompson (1992) listed three specific and integrated phases of this planning:
1. Determine the goals of treatment Is cure a
goal, or is the goal a peaceful death at home?
These goals need to be patient-focused,
reality-centered, and attainable. They should
be consistent with current medical treatment
and, if possible, measurable according to an
2. Identify the decision makers As mentioned
earlier, nurses may not be decision makers in
these health-related ethical dilemmas. It is
important to know who the decision makers
are and their belief systems. A patient who
has the capability to participate makes the
chapter 2 ■ Professional Ethics and Values
task less complicated. However, critically ill or
terminally ill patients may be too exhausted to
speak for themselves or ensure their voices are
heard. When this happens, the patient needs
an advocate, which might be family members,
friends, spiritual advisors, or nurses. A family
member may need to be designated as a
primary decision maker or health-care surrogate.
The creation of living wills, advance directives,
and the appointment of a health-care surrogate
while a person is healthy often eases the
burden for the decision makers during a later
crisis. These are discussed in more detail in
3. List and rank all the options Performing
this task involves all decision makers. It is
sometimes helpful to begin with the least
desired choice and methodically work toward
the preferred treatment choice that will most
likely produce the desired outcome. Engaging
all participating parties in a discussion
identifying each one’s beliefs regarding
attaining a reasonable outcome using available
medical expertise often helps. Often sharing
ideas in a controlled situation allows everyone
involved to realize that everyone wants the
same goal but perhaps has varying opinions on
how to reach it.
During the implementation phase, the patient
or surrogate (substitute) decision maker(s) and
members of the health-care team reach a mutually acceptable decision. This occurs through open
discussion and negotiation. An example of negotiation follows:
Olivia’s mother, Angela, has Stage IV ovarian
cancer. She and Olivia have discussed treatment options. Angela’s physician suggested the
use of a new chemotherapeutic agent that has
demonstrated success in many cases. Angela
states emphatically that she has “had enough”
and prefers to spend her remaining time doing
whatever she chooses. Olivia wants her mother
to try the medication. To resolve the dilemma,
the oncology nurse practitioner and physician
speak with Olivia and her mother. Everyone
reviews the facts and expresses their feelings.
Seeing Olivia’s distress, Angela says, “OK, I
will try the drug for a month. If there is no
improvement after this time, I want to stop all
treatment and live out the time I have with my
daughter and her family.” All agreed that this
was a reasonable decision.
The role of the nurse during the implementation phase is to ensure the communication remains
open. Ethical dilemmas are emotional issues, filled
with guilt, sorrow, anger, and other strong emotions. These strong feelings create communication
failures among decision makers. Remind yourself
of the three ethical principles: autonomy, beneficence, and nonmaleficence, and think, “I am here
to do what is best for this patient.”
Keep in mind that an ethical dilemma is not
always a choice between two attractive alternatives.
Many dilemmas revolve around two unattractive,
even unpleasant choices. In the previous scenario,
Angela’s choices did not include what she truly
wants: good health and a long life.
Once an agreement is reached, the decision
makers must accept it. Sometimes an agreement
cannot be reached because the parties are unable to
reconcile their conflicting belief patterns or values.
At other times, caregivers are unable to recognize
the worth of the patient ’s point of view. Occasionally, the patient or surrogate may make a request
that is not institutionally or legally possible. When
this occurs, a different institution or physician may
be able to honor the request. In some instances,
a patient or surrogate may ask for information
that reflects illegal acts. When this happens, the
nurse needs to explore whether the patient and
the family considered the consequences of their
proposed actions. This now presents a dilemma for
the nurse as, depending on the request, he or she
may need to notify upper-level administration or
the authorities. This conflicts with the principle of
confidentiality. It may be necessary to bring other
counselors into the discussion (with the patient ’s
permission) to negotiate the agreement.
As in the nursing process, the purpose of evaluation in resolving ethical dilemmas is to determine
whether the desired outcomes have occurred. In
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The MORAL Model
M: Massage the dilemma
O: Outline the option
R: Resolve the dilemma
A: Act by applying the chosen option
L: Look back and evaluate the complete process,
including actions taken
the case of Mr. Rodney, some of the questions
that could be posed by Gloria to the family are
“I have noticed the amount of time you have
been spending with your father. Have you
observed any changes in his condition?”
■ “I see the neurologist spoke to you about the
test results and your father’s prognosis. How do
you feel about the situation?”
■ “Now that the neurologist spoke to you about
your father’s condition, have you considered
Changes in patient status, availability of medical
treatment, and social factors may call for reevaluation of a situation. The course of treatment may
need to be altered. Continued communication
and cooperation among the decision makers are
Another model, the MORAL model created
by Thiroux in 1977 and refined for nursing by
Halloran in 1992, has gained popularity and is
considered a standard for dealing with ethical
dilemmas (Toren & Wagner, 2010). This ethical
decision-making model is easily implemented in
all patient care settings (Box 2-3).
Current Ethical Issues
Probably one of the most well-known events that
brought attention to some of the ethical dilemmas regarding end-of-life issues occurred in
1988 when Dr. Jack Kevorkian (sometimes called
Dr. Death by the media) openly admitted to giving
some patients, at their request, a lethal dose of
medication, resulting in the patients’ deaths. His
statement raised the consciousness of the American people and the health-care system about
the issues of euthanasia and assisted suicide. Do
individuals have the right to consciously end their
own lives when they are suffering from a terminal
condition? If they are unable to perform the act
themselves, should others assist them in ending
their lives? Should assisted suicide be legalized?
Physician-assisted suicide is currently legal in eight
jurisdictions; Oregon was one of the first states,
and in 2018 Hawaii recognized this legal right
with the passage of the Our Choice Act (ProCon
The Terri Schiavo case gained tremendous
media attention, probably becoming the most
important case of clinical ethics as it brought
forward the deep divisions and fears that reside
in society regarding life and death, as well as the
role of the government and courts in these decisions (Quill, 2005). Many aspects of the case may
never be completely clarified; however, it raised
many questions that laid the groundwork for
present ethical decisions in similar situations and
The primary goal of nursing and health-care
professions is to keep people alive and well or, if
this cannot be done, to help them live as comfortably as possible and achieve a peaceful death.
To accomplish this end, health-care professionals
struggle to improve their knowledge and skills so
they can care for their patients and provide the
best quality of life possible. The costs involved in
achieving this goal can be astronomical.
Questions are being raised more and more
about who should receive the benefits of technology. The competition for resources also creates
ethical dilemmas. Other difficult questions, such
as who should pay for care when the illness may
have been caused by poor health practices such as
smoking and substance abuse, are now under consideration. Many employers and health insurance
companies evaluate the health status of individuals
before determining the cost of their health-care
premiums. For example, individuals who smoke
or are overweight are considered to have a higher
risk for chronic disease. Individuals with less risky
behaviors and better health indicators may pay less
for coverage (CDC, 2015).
Practice Issues Related to Technology
Technology and Treatment
In issues of technology, the principles of beneficence and nonmaleficence may be in conflict. For
example, a specific advancement in medical technology administered with the intention of “doing
chapter 2 ■ Professional Ethics and Values
good” may cause harm. At times, this is an accepted
consequence and the patient is aware of the risk.
However, in situations where little or no improvement is expected, the issue becomes whether the
benefit outweighs the risk. Suffering from induced
technology may include multiple components for
the patient and family.
Today, many infants born prematurely or
with extremely low birthweights who long ago
would have been considered unable to survive
are maintained on mechanical devices in highly
sophisticated neonatal units. This process may
keep the infants alive only to die later or live with
chronic, and often severe, disabilities. These children require highly technological treatments and
specialized medical, educational, and supportive
The use of ultrasound throughout a pregnancy
is supported by evidence-based practice and is a
standard of care. In the past, these pictures were
mostly two-dimensional and used to determine
fetal weight and size in relation to the mother’s pelvic anatomy. Today, this technology has
evolved to where the fetus’s internal organ structure is visualized, and defects not known before are
detectable. This presents parents with additional
options, leading to other decisions.
Technology and Genetics
Genetic diagnosis is a process that involves analyzing the parents or an embryo for a genetic disorder.
This is done before in vitro fertilization. Once the
egg is fertilized, the embryos are tested, and only
those without genetic flaws are implanted. Genetic
screening of parents has also entered the standard
of care, particularly in the presence of a family
history. Parents are offered this option when
seeking prenatal care. Some parents refuse to have
genetic testing as their value and belief systems
preclude them from making a decision that may
lead to terminating the pregnancy.
Genetic screening leads to issues pertaining to reproductive rights and also opens new
issues. What is a disability versus a disorder, and
who decides? Is a disability a disease, and does
it need to be prevented? The technology is also
used to determine whether individuals are predisposed to certain diseases such as Alzheimer’s
or Huntington’s chorea. This has created additional ethical issues regarding genetic screening.
Christy, who is 32 years old, is diagnosed with
a nonhormonally dependent breast cancer.
She has two daughters, ages 6 and 4 years
old, respectively. Christy ’s mother and maternal grandmother had breast cancer, and her
maternal grandfather died from prostate cancer.
Neither her mother nor grandmother survived
more than 5 years post-treatment. Christy ’s
physician suggested she obtain genetic testing
for the BRCA1 and BRCA2 genes before deciding on a treatment plan. Christy meets with the
nurse geneticist and asks the following questions: “If I am positive for the genes, what are
my options? Should I have a bilateral mastectomy with reconstruction? Will I be able to get
health insurance coverage, or will the company
charge me a higher premium? What are the
future implications for my daughters?”
As the nurse, how might you address these
Genetic engineering is the ability to change
the genetic nature of an organism. Researchers
have created disease-resistant fruits and vegetables
as well as certain medications using this process.
Theoretically, genetic engineering allows for the
genetic alteration of an embryo, eliminating genetic
flaws and creating healthier babies. Envision being
able to “engineer your child.” Imagine, as Aldous
Huxley did in Brave New World (1932), being able
to create a society of perfect individuals: “We also
predestine and condition. We decant our babies as
socialized human beings, as Alphas or Epsilons
as future sewer workers or future . . . he was going
to say future World controllers but correcting
himself said future directors of Hatcheries instead”
(p. 12). The ethical implications pertaining to
genetic technology are profound. For example,
some of the questions raised by the Human
Genome Project related to:
Fairness in the use of genetic information
Privacy and confidentiality of obtained genetic
■ Genetic testing of an individual because of a
However, genetics has also allowed health-care
providers to identify individuals who may have
a greater risk for heart disease and diabetes and
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begin early treatment and lifestyle changes to
minimize or prevent the onset or complications
of these disorders. Pharmacogenetics presently
incorporates pharmacology and genetics and
allows more targeted treatments for individuals by
addressing their genetic makeup.
DNA Use and Protection
Recently, Butler (2015) approached the subject
of DNA use and protection. Presently, DNA is
mostly used in forensic science for the identification of individuals, military personnel, or possible
criminal evidence. However, questions remain as
to the protection of this information and what
is considered legal usage. The birth of companies
that offer individuals the ability to discover their
DNA and ancestral origins presents a greater level
of concern both legally and ethically.
Stem Cell Use and Research
Stem cell use and research issues have emerged
during this decade. Stem cell transplants for the
treatment of certain cancers are considered an
acceptable treatment option when others have
failed. They are usually harvested from a matching donor. The ethics of stem cell use focuses on
how to access them. Should fetal tissue be used to
harvest stem cells? Companies now offer prospective parents the option of obtaining and storing
fetal cord blood and tissue for future use should
the need arise. Although this is costly and not
covered by insurance, many parents opt to do this.
When faced with the prospect of a child who
is dying from a terminal illness, some parents have
resorted to conceiving a sibling for the purpose of
harvesting stem cells from the sibling to save the
life of the ill child. Nurses who work in pediatrics
and pediatric oncology units may find themselves dealing with this situation. It is important
for nurses to examine their own feelings regarding these issues and understand that, regardless of
their personal beliefs, the family is in need of sensitivity and the best nursing care.
Most of this chapter dealt with patient issues;
however, ethical problems may involve leadership
and management issues. What should you do
about an impaired coworker? Personal loyalties
may cause conflict with professional ethics, creating an ethical dilemma. For this reason, most nurse
practice acts address this concern and require the
reporting of impaired professionals while also providing rehabilitation for those who need it.
Other professional dilemmas revolve around
competence. How do you deal with incompetent
health-care personnel? This situation frustrates
both staff and management. Regulations created to
protect individuals from unjustified loss of position
and the magnitude of paperwork, remediation, and
the time it takes to terminate an incompetent
health-care worker often compel management to
tolerate the situation.
Employing institutions that provide nursing
services have an obligation to establish a process
for reporting and handling practices that jeopardize patient safety (Gong, Song, Wu, & Hua,
2015). The behaviors of incompetent staff place
patients and other staff members in jeopardy.
Eventually, the incompetency may lead to legal
action that could have been avoided if appropriate
leadership pursued a different approach.
Nurses and other health-care personnel find themselves confronting more ethical dilemmas in this
ever-changing health-care environment. More
questions are being raised with fewer answers
available. New guidelines need to be developed
to assist in finding viable solutions to these challenging questions. Technology wields enormous
power to alter the human organism, the promise
to eradicate diseases that plague humankind, and
the ability for health-care professionals to prolong
human life. However, fiscal resources and economics may force the health-care profession to rethink
answers to questions such as, “What is life versus
living?” and “When is it okay to terminate a human
life?” Will society become the brave new world of
Aldous Huxley? Again and again the question is
raised, “Who shall live and who shall die?” How
will you answer?
chapter 2 ■ Professional Ethics and Values
1. What is the difference between intrinsic and extrinsic values? Make a list of your intrinsic
2. Consider a decision you recently made that you based on your values. How did you make your
3. Describe how you could use the valuing process of choosing, prizing, and acting in making the
decision considered in Question 2.
4. Which of your personal values would be primary if you were assigned to care for an
anencephalic infant whose parents have decided to donate the baby ’s organs?
5. The parents of the anencephalic infant in Question 4 confront you and ask, “What would you
do if this were your baby?” What do you think would be most important for you to consider in
responding to them?
6. Your friend is single and feels that her “biological clock is ticking.” She decides to undergo
in vitro fertilization using donor sperm. She tells you that she has researched the donor’s
background extensively and wants to show you the “template” for her child. She asks for
your professional opinion about this situation. How would you respond? Identify the ethical
7. During the past several weeks, you have noticed that your closest friend, Jamie, has been erratic
and making poor patient care decisions. On two separate occasions you quietly intervened
and “fixed” his errors. You have also noticed that he volunteers to give pain medications to
other nurses’ patients, and you see him standing very close to other nurses when they remove
controlled substances from the medication distribution system. Today, you watched him go
to the center immediately after another colleague and then saw him go into the men’s room.
Within about 20 minutes his behavior changed completely. You suspect that he is taking
controlled substances. You and Jamie have been friends for more than 20 years. You grew up
together and went to nursing school together. You realize that if you approach him, you may
jeopardize this close friendship that means a great deal to you. Using the MORAL ethical
decision-making model, devise a plan to resolve this dilemma.
Case Study to Promote Critical Thinking
Andy is assigned to care for a 14-year-old girl, Amanda, admitted with a large tumor located in
the left groin area. During an assessment, Amanda shares her personal feelings with Andy. She
tells him that she “feels different” from her friends. She is ashamed of her physical development
because all her girlfriends have “breasts” and boyfriends. She is very flat-chested and embarrassed.
Andy listens attentively to Amanda and helps her focus on some of her positive attributes and
A computed tomography (CT) scan is ordered and reveals that the tumor extends to what
appears to be the ovary. A gynecological surgeon is called in to evaluate the situation. An
ultrasonic-guided biopsy is performed. It is discovered that the tumor is actually an enlarged
lymph node, and the “ovary” is actually a testis. Amanda has both male and female gonads.
When the information is given to Amanda’s parents, they do not want her to know. They feel
that she was raised as “their daughter.” They ask the surgeon to remove the male gonads and leave
unit 1 ■ Professionalism
only the female gonads. That way, “Amanda will never need to know.” The surgeon refuses to do
this. Andy believes the parents should discuss the situation with Amanda as they are denying her
choices. The parents are adamant about Amanda not knowing anything. Andy returns to Amanda’s
room, and Amanda begins asking all types of questions regarding the tests and the treatments.
Andy hesitates before answering, and Amanda picks up on this, demanding he tell her the truth.
1. How should Andy respond?
2. What ethical principles are in conflict?
3. What are the long-term effects of Andy ’s decision?
NCLEX®-Style Review Questions
1. Several studies have shown that although care planning and advance directives are available to
clients, only a minority actually complete them. Which of the following has been shown to be
related to completing an advance directive? Select all that apply.
1. African American race
2. Younger age
3. History of chronic illness
4. Lower socioeconomic status
5. Higher education
2. The ANA Code of Ethics With Interpretive Statements guides nurses in ethical behaviors.
Provision 3 of the ANA Code of Ethics says: “The nurse promotes, advocates for, and strives to
protect the health, safety, and rights of the patient.” Which of the following best describes an
example of this provision?
1. Respecting the patient ’s privacy and confidentiality when caring for him
2. Serving on a committee that will improve the environment of patient care
3. Maintaining professional boundaries when working with a patient
4. Caring for oneself before trying to care for another person
3. Health Insurance Portability and Accountability Act (HIPAA) regulations guard
confidentiality. In several situations, confidentiality can be breached and information can be
reported to other entities. Which of the following meet these criteria? Select all that apply.
1. The patient is from a correctional institution.
2. The situation involves child abuse.
3. An injury occurred from a firearm.
4. The patient is a physician.
5. The breach of information was unintentional.
4. A patient asks a nurse if he has to agree to the health provider’s treatment plan. The nurse
asks the patient about his concerns. Which ethical principle is the nurse applying in this
situation? Select all that apply.
Guidelines for Seminar Assignments
All students will actively participate in seminar assignments by:
1. Joining a group or as individual to prepare a group presentation on a specified
2. Actively assisting the group or individually to develop the presentation, handouts,
videos, games and any other needed materials.
3. Actively presenting the group presentation ( instructors’ preference)
4. Reviewing the presentation comments with members of the group for
improvement and/or feedback from instructor
Group Presentation Topics include:
These are the objectives and questions needed for your presentations: Please be as creative as
possible, to include role playing, PowerPoint slides, Preszi presentations, Sway presentations,
Kahoot, pamphlets, games and any other teaching strategy that is available for your
use. Presentations should be between 30 – 45 minutes and allow at least 5 minutes for
SEMINAR TOPICS AND QUESTIONS TO ANSWER:
Leadership and Management:
Compare and contrast different leadership theories.
Describe the different types of power that leaders use.
What is nursing empowerment?
What is shared governance?
Differentiate the roles of manager and leader.
Compare and contrast the various levels of management.
Describe the classical functions of management.
Discuss ways to become an effective leader.
1. Why do nurses/nursing students need to know about time management?
2. What are some common time wasters for nurses/nursing students?
3. Describe some time management tips for nurses/nursing students.
Quality and Safety Education for Nurses (QSEN)
What is the meaning of QSEN?
What is QSEN in nursing?
What are the Institute of Medicine (IOM) Core Competencies?
What are the six core competencies for pre-licensure nursing programs?
5. What is quality improvement in QSEN?
Delegation and Prioritization of client care & Scope of Practice:
Differentiate delegation from work allocation.
Describe the benefits of delegation.
Describe the delegation process.
Discuss the difficulties with and obstacles to delegation of patient care.
What are the “Rights of Delegation” according to the Florida Board of Nursing?
What is prioritization of care and why is this important?
Review Maslow’s Hierarchy of Needs in relation to prioritizing care.
What is meant by scope of practice?
What is the scope of practice for RNs, LPNs, PCTs, NAs and UAPs
Ethical Issues in Nursing
Is there a difference between personal ethics and professional ethics?
Compare and contrast various ethical theories.
Think of an ethical issue and apply the seven basic ethical principles to it.
What is a code of ethics?
Review some current ethical issues noted in health care.
What is an ethical dilemma in nursing?
How are ethical dilemmas resolved in nursing?
Impairment in the Workplace
What is impairment in the workplace?
What are the signs of impairment?
Identify both behavioral and physical signs of impairment in the workplace.
Discuss the Intervention Program for Nurses (IPN).
What programs and initiatives do some employers offer to promote safety and provide
6. What are the treatment options for impairment in the workplace?
Florida Laws and Rules & Legal Issues in Nursing
What are the 3 sources of laws?
Explain the differences of various types of laws.
Differentiate between negligence and malpractice.
Discuss some nursing actions that can lead to malpractice lawsuits?
What are intentional and unintentional torts?
Discuss other laws that are relevant to nursing practice.
How are standards of care used in determining negligence and malpractice?
Describe how nurse practice acts guide nursing practice.
9. Review Florida’s Nurse Practice Act (NPA), what we really need to know.
10. What is the purpose of licensure?
11. How do nurses become licensed?
12. What is multistate licensure? Is Florida included in a compact licensure? Are all nurses
included in the compact? How do nurses in Florida join the compact?
13. Why and how are nurses disciplined?
14. What must nurses do to keep their licenses?
15. What are internal vs external standards?
16. What are advance directives and how do they pertain to patients?
17. What are the legal implications of the Health Insurance Portability and Accountability
18. What must be included in a DNR order?
19. What are Living Wills and a Durable Power of Attorney for Health Care?
1. Describe the factors influencing communication.
2. Describe the role of assertiveness in communication.
3. What are some of the barriers to effective communication among health care providers
4. What are the electronic forms of communication in nursing and healthcare?
5. Discuss the rules of netiquette.
6. What is SBAR and ISBARR, why are they important in nursing? Please review with
7. How does QSEN define teamwork? Why is it important to be a team player?
What is conflict?
Discuss the many common sources of conflict.
Describe the positive and negative aspects of conflict.
Compare and contrast different ways of managing conflict.
What is problem resolution and how is it utilized?
Is there a difference between problem resolution and negotiation?
What is collective bargaining?
What is the process of change?
Compare and contrast change theories.
What is resistance to change, how do you recognize it and what can you do about it?
Explain the steps of planned change.
Compare and contrast change agent strategies.
Describe the skills that a change agent needs.
1. Review nursing organizations and their purpose – American Nurses Association (ANA),
Florida Nurses Association (FNA), National League for Nursing (NLN), American Nurses
Credentialing Center (ANCC) and the Florida Center for Nursing (FCN).
2. Other national nursing organizations: National Black Nurses Association (NBNA),
National Hispanic Nurses Association (NHNA), Haitian American Nurses Association
(HANA). Other local and national organizations that you can find (AORN, ERNA, etc)
3. What are the Core Competencies for Health Professionals according to the Institute of
Medicine’s (IOM) report?
Other Issues in Nursing & Healthcare
What is Magnet Status?
Explain the steps in becoming a Magnet facility.
What are Core Measures?
What is the purpose of the Joint Commission?
What are the 2018 National Patient Safety Goals and what purpose do they serve?
Please review the goals for 2020.
Discuss the Hospital Consumer Assessment of Healthcare Providers and Systems
8. Why are HCAPS important in nursing?
All information can be found in your textbook for the course, or on the web. You must cite your
sources on your PowerPoint slides or handouts in APA format.
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