Ethics Essay

The purpose of this assignment is to examine ethics and ethical issues in relation to nursing practice. It will define ethics, discuss its relevance to nursing and identify challenges that nurses may face when dealing with ethics in practice. The assignment will identify an ethical issue encountered during a recent clinical placement; it will examine this issue in relation to two ethical principles and discuss how these principles conflict each other in this situation. The assignment will then discuss a professional response a nurse could carry out in this situation. Finally, it will provide a summary on what has been learned while completing this assignment.

The relevance and challenges of ethics in nursing.
Ethics may be defined as “a set of concepts and principles that guide us in determining what behaviour helps or harms sentient creatures” (Paul & Elder, 2009, p. 1). Ethics involves moral consideration in determining what is right and wrong, good and bad (Chaloner, 2007). Thus ethics is very relevant to the nursing profession.

Jones (2009) identifies several qualities relating to the definition of nursing, some of which include: supporting independence, promoting health, preventing illness and advocating for health consumers. When considering the four moral principles of ethics: autonomy, beneficence, non-maleficence and justice it can be seen that, respectively, these moral principles can be directly related to the qualities above (Chaloner, 2007). Thus nursing is an ethical practice in itself as it involves the continuing consideration of a set of moral values and ethics held by the profession (Chaloner, 2007).

In New Zealand, nursing has its own code of ethics which serves to both offer ethical guidance to nurses and to provide a level of transparency to society about the ethical values of the profession (New Zealand Nurses Organisation [NZNO], 2010). Having a body of ethics provides a profession with a moral stance that empowers meaning and motivation to the work of that profession (Churchill, as cited in Griffiths, 2009). However, even with this guidance nurses may find themselves challenged with ethical issues.

An ethical issue can be defined as a moral problem for which there are two or more courses of action that are either equally beneficial or equally undesirable (Kennedy, 2004; Griffiths, 2009). One ethical issue nurses may face is a conflict between the law and ethics; because they are both a form of regulation this can present a challenge (Chaloner, 2007). For example, abortion is legal though some believe unethical, while voluntary euthanasia is illegal though some believe ethical (Griffiths, 2009).

Moral disagreement presents another ethical challenge in nursing (Beauchamp & Childress, 2009). The different values and beliefs of individuals involved with the issue are inevitably going to influence the way in which they interpret certain aspects of the dilemma (Griffiths, 2009). This can result in differing opinions and thus disagreement as to the best course of action (Beauchamp & Childress, 2009). Moral disagreements may represent personal issues for nurses when their individual morals conflict with those of the law or the nursing code of ethics (Johnstone, 2009).

An ethical issue identified in a recent clinical placement. An ethical issue identified during a recent clinical placement related to a client receiving treatment under the Mental Health (Compulsory Assessment and Treatment) Act 1992 (MHA) (Ministry of Health [MOH], 2012). This client had a psychotic disorder diagnosis and had been admitted to an inpatient psychiatric ward for acute psychosis twice within the first year of diagnosis. Lack of insight regarding the correlation between medication and wellness resulted in the client ceasing to take prescribed medication, resulting in deterioration to acute mental illness. The severity of the client’s acute illness was such that the hallucinations and delusional behaviour resulted in violence and property damage; posing a significant safety risk for themself and others.

The first key point in this ethical issue is that the client ardently disagreed with the diagnosis and, as such, did not want to take medication for it. However, several reasons resulted in the client receiving treatment under the MHA for the purpose of administering antipsychotic medication. First, the client’s history and evident lack of insight indicated that the likelihood of non-compliance with prescribed medication (and thus a subsequent decline in mental wellness) was high. Second, the client had a history of exhibiting behaviour that was a significant safety concern to themself and others when acutely unwell. Furthermore, the client continued to display delusional behaviour that was a core factor in their risk to others. All four ethical principles could be considered to relate to this situation, however the crux of the ethical issue is the client’s autonomy regarding their healthcare decisions vs. beneficence in relation to what is best for the client – which principle should be upheld?

An analysis of the issue in relation to two ethical principles. Autonomy relates to an individual’s right to act and make decisions of their own volition without coercion or interference from others; it recognises that each individual is best equipped to decide what is best for them (Beauchamp & Childress, 2009). Autonomy is closely related to the concept of competence; for a person to be considered as making an autonomous choice they must have both sufficient understanding and capacity to make a meaningful choice (Epright, 2010; Beauchamp & Childress, 2009). This means that a person should have adequate information and “the ability to reason, judge, and assess consequences” in order to make an autonomous decision (Epright, 2010, p. 800).

In this situation, considering the basic definition of autonomy, the decision to place the client under the MHA could be viewed as a violation of the client’s autonomy (O’Brien, Maude & Muir-Cochrane, 2013). The reason for placing the client under the MHA was to administer treatment that the client did not want and would otherwise not have accepted. Effectively, this decision (and the actions taken to enforce it), although undertaken with the clients best interests in mind, was a form of interference and coercion by health professionals and the legal system; this is called paternalism (Epright, 2010).

In considering the abilities that are necessary for a choice to be considered competent and thus autonomous (understanding, reasoning, judgement and assessing consequences), the situation could be considered in a different light when looking at the compromise that psychotic disorders bring to these abilities (Epright, 2010). This can put the client at risk of making choices that they might not make if their capacities were fully intact and thus questions whether their decisions were truly autonomous (Epright, 2010).

This particular client had a history of, and was currently, exhibiting behaviour that compromised the autonomy and safety of others. In this situation, it may be considered appropriate to temporarily restrict the autonomy of the client with the goal of protecting their capacities for decision making (and respecting others autonomy) in the future; thus the aim is to promote the person’s future autonomy (Epright, 2010; Beauchamp & Childress, 2009). Therefore, the paternalistic approach to treating this client could be considered beneficent.

Beneficence relates to an obligation to act in a manner that benefits others (Beauchamp & Childress, 2009). It involves positive action that promotes good by enhancing the wellbeing and interests of others, preventing harm and protecting others rights (Beauchamp & Childress, 2009). Beneficence also involves a balance of costs, benefits and risks against outcomes (Beauchamp & Childress, 2009). Finally, an act of beneficence should respect, and aim to increase, an individual’s autonomy (Kennedy, 2004; Gillon, 1994).

If actions must respect an individual’s autonomy and protect their rights in order to be deemed beneficent, it may be considered that the actions in this situation were not entirely beneficent. However, while the Code of Health and Disability Services Consumers’ Rights states that “every consumer has the right to refuse services […]” (p. 3), it also states that if there are reasonable grounds to believe the individual is not competent, then informed consent may not be mandatory (Health and Disability Commissioner, 2004). Therefore, while the individual was not granted the right to refuse treatment, they were deemed as not competent to make that decision, thus legally allowing the health team to override the client’s refusal. Furthermore, if a lack of recognition of the client’s autonomy negates beneficent action, this would also call into question the definition of autonomy and the capacities required for autonomous choice.

In this situation, given the strong correlation between medication and the client’s mental status and their history of behaviour when they were unwell, it could be (and was) considered beneficial to enforce a mandatory treatment order (Barker, 2011). Ensuring the client receives medication to maintain wellness promotes good by enhancing the client’s future wellbeing and preventing potential harm by minimising the risk of behaviour associated with unwellness (Epright, 2010). Furthermore, given that the nature of the client’s illness affected their capacity for decision making, providing medication to treat the illness could be considered a beneficent measure to increase that person’s future autonomy (Epright, 2010).

Discussion on how the two principles conflict each other.
In this situation, while the principle of beneficence supports respecting a person’s autonomy, overall these two principles conflict each other. The NZNO (2010) Code of Ethics and the NZNO (2012) Standards of Professional Nursing Practice both dictate that it is nurses’ moral duty to respect the autonomy of clients. However, it is also a nurse’s moral duty to act beneficently toward clients (NZNO, 2010; NZNO, 2012). In this instance, both respecting the client’s autonomy and acting beneficently toward them is incompatible.

There is legislation in New Zealand that provides for situations where a person’s capacities to make rational and autonomous choice is compromised (MOH, 2012). The MHA is a legal framework that allows health professionals to provide compulsory treatment to clients who are affected by a mental disorder that compromises their ability to make decisions to the point where the consequences may be harmful to themselves or others (MOH, 2012). In this instance, the legislation meant that the nurse could act beneficently for the client who would otherwise refuse care and treatment that was beneficial to them (Barker, 2011; Muir-Cochrane, O’Brien & Wand, 2013). However, while this directly conflicts with the client’s autonomy surrounding healthcare, it yet again calls into question the definition of autonomy and the requirements for autonomous choice.

A professional response a registered nurse could undertake to promote the best outcome. In this situation, the nurse was not able to alter the community treatment order that was at the core of the autonomy vs. beneficence issue. However, the way in which the nurse provides treatment and relates to the client during the relationship can have an effect on the overall outcome (O’Brien, Maude & Cochrane, 2013). When autonomy is in part restricted by mental health legislation, the nurse is still able to promote autonomy by involving the client with decision making in other areas (O’Brien, Maude & Cochrane, 2013). By encouraging the client to participate in selecting medications, establishing a care plan and choosing times and places for medication administration (if it is an injection) the nurse can increase the client’s autonomy and therefore promote a better outcome (O’Brien, Maude & Cochrane, 2013; Snowden, 2011).

Another way to promote the best possible outcome for the client is to ensure that the client is informed about, and involved with, decisions relating to their health care (O’Brien, Maude & Cochrane, 2013; Tong, 2007). Although mental health conditions may impair the capacities required to make autonomous decisions and thus deem the client incompetent, the client should still be actively involved with decisions relating to their health care (Epright, 2010). By ensuring the client is involved in their care, the nurse can promote a better outcome by fostering a good nurse-client relationship which can help the nurse and client work toward the goal of wellness together, as opposed to with a paternalistic approach (Stein-Parbury, 2009). Additionally, the nurse can advocate for the client when necessary to ensure that the client’s individual views and culture are recognised and respected (McMurray, 2009).

Summary of what has been learned.
In learning the relevance of ethics to nursing, I have realised that the very nature of nursing involves the application of ethics to practice on a daily basis. While there will be occasions where the answer to an ethical issue may not be so clear cut, the support of colleagues and clinical guidelines can help determine the approach to take. Furthermore, these clinical guidelines also provide an example to consumers regarding the standards expected in nursing practice.

Most importantly, I have learned that ethical issues are multifaceted and there is no ‘one size fits all’ answer to ethical questions. Culture, values and context vary within every ethical issue and thus each issue must be considered with these in mind. There may not always be a ‘right’ answer in an ethical situation and those involved may not agree on the best decision; however, by approaching ethics with an open mind and basing decisions on available information while using relevant nursing guidelines, I can provide justification for my stance on an issue.

Finally, I have learned that there will always be situations where ethical principles conflict with each other. In these instances it is necessary to consider all aspects of the situation and weigh up any costs, risks and benefits against possible outcomes in order to decide on which principle the emphasis should lie in the given situation. While some situations result in a decision to uphold a particular ethical issue to the point that it compromises another, nurses can still work with clients to promote aspects of ethical principles that may not be affected by the decision.

Conclusion
In conclusion, ethics is a set of moral principles that provides a basis for human behaviour. Ethics is extremely relevant to nursing practice and not only will nurses encounter ethical decisions regularly, they will also face challenges when approaching ethical issues. Relevant New Zealand legislation and nursing guidelines provide direction to nurses who encounter ethical issues and also provide a level of transparency to consumers regarding the expected standards of nursing practice. A recent clinical placement provided an example of an ethical issue; an analysis of this issue in relation to the principles of autonomy and beneficence highlighted the fact that ethical problems are multifaceted and contextual. Additionally, in discussing this ethical issue it is apparent that ethical principles can sometimes conflict each other to the point that one must be chosen over another. Finally, nurses must act as advocates for clients and promote ethical principles to the best of their abilities even when circumstances mean that certain aspects of an ethical principle are restricted.