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ETHICAL ISSUES AND ETHICAL
DECISION MAKING IN NURSING
Bagian Keperawatan Klinik
FAKULTAS ILMU KEPERAWATAN
UNIVERSITAS PADJADJARAN
Kusman Ibrahim, PhD
Ethical Issues
Issues: dominate the newspaper headlines and Issues: dominate the newspaper headlines and
become concerns of all members of society become concerns of all members of society
Ethical issues: Ethical issues:
-- Termination of treatment decisions Termination of treatment decisions
-- Abortion Abortion
-- In vitro fertilization In vitro fertilization
-- Surrogate motherhood Surrogate motherhood
-- Euthanasia & assisted suicide Euthanasia & assisted suicide
-- Allocation of scarce resources Allocation of scarce resources
-- Treatment of disabled infants and the mentally Treatment of disabled infants and the mentally
retarded retarded
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Termination of Treatment Decisions
Treating patients: When to intervene and to what end? Treating patients: When to intervene and to what end?
Withholding or withdrawing life Withholding or withdrawing life--sustaining treatments when sustaining treatments when
they are deemed to have poor outcomes or offer no benefit they are deemed to have poor outcomes or offer no benefit
Hippocrates: medicine was to relieve suffering and reduce Hippocrates: medicine was to relieve suffering and reduce
the effects of disease by lending support to natural the effects of disease by lending support to natural
processes processes
Medical futility: situations in which interventions are judged Medical futility: situations in which interventions are judged
to have no medical benefit, or in which the chance for to have no medical benefit, or in which the chance for
success is low success is low
Withholding or removing life Withholding or removing life--sustaining treatments in sustaining treatments in
situations in which the burden or harm has been determined situations in which the burden or harm has been determined
to outweigh the benefits the benefits is, in essence, allowing to outweigh the benefits the benefits is, in essence, allowing
the person to die as a result of the natural progression of the person to die as a result of the natural progression of
the illness process the illness process
Abortion
Mothers right to control her body and her life (right to Mothers right to control her body and her life (right to
choose) Vs right of the unborn fetus to a chance at life choose) Vs right of the unborn fetus to a chance at life
(right to life) (right to life)
Belief of right Belief of right--to to--life: abortion constitutes murder of an life: abortion constitutes murder of an
unborn person, it is a legal as well as an ethical matter unborn person, it is a legal as well as an ethical matter
Values in relation to life: when life begins, quality of life Values in relation to life: when life begins, quality of life
for unwanted child, concerns about mothers life and for unwanted child, concerns about mothers life and
health health
Opponents : a fetus possesses humanity in accord all Opponents : a fetus possesses humanity in accord all
human right , including the right to life human right , including the right to life
Proponents: based on autonomy, a woman has a right Proponents: based on autonomy, a woman has a right
to her own body, and that no woman should be forced to to her own body, and that no woman should be forced to
bear a child that she does not want. bear a child that she does not want.
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Euthanasia & assisted suicide Euthanasia & assisted suicide
Causing the painless death of a person in order to end Causing the painless death of a person in order to end
or prevent suffering or prevent suffering
Active voluntary euthanasia is an act in which the Active voluntary euthanasia is an act in which the
physician both provides the means of death and physician both provides the means of death and
administers it. administers it.
Assisted suicide: the patients receive the means of Assisted suicide: the patients receive the means of
death from someone (physician, nurse), but activate the death from someone (physician, nurse), but activate the
process themselves process themselves
Proponents: respect for the persons autonomy in Proponents: respect for the persons autonomy in
choosing to end his/her life if it is deemed intolerable choosing to end his/her life if it is deemed intolerable
due to conditions of a terminal illness or suffering due to conditions of a terminal illness or suffering
Opponents: sanctity of life, any act violates the Opponents: sanctity of life, any act violates the
prohibition against killing human beings. prohibition against killing human beings.
Reproductive Technology Reproductive Technology
Artificial insemination by donor, in vitro fertilization, Artificial insemination by donor, in vitro fertilization,
surrogate embryo transfer surrogate embryo transfer
Moral implication of their use Moral implication of their use potential for changing potential for changing
societys concept of family and parenthood societys concept of family and parenthood
Who is the mother of the baby? Who is the mother of the baby?
Who has custody of frozen embryos? Do these embryos Who has custody of frozen embryos? Do these embryos
have rights? have rights?
Who should pay for them? For whom they should be Who should pay for them? For whom they should be
made available? (social justice) made available? (social justice)
Who should or should not have children, and what kind Who should or should not have children, and what kind
of children should be born? of children should be born?
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Organ and Tissue Procurement and Organ and Tissue Procurement and
Transplantation Transplantation
By advancement of technology By advancement of technology the possibility the possibility
of a transplant become a hope for people afflicted of a transplant become a hope for people afflicted
with the failure of a vital organ with the failure of a vital organ
Demand >> supply Demand >> supply dilemma related to dilemma related to
allocation of scarce resource allocation of scarce resource
Who is the eligible recipients? Potential survival Who is the eligible recipients? Potential survival
post post--transplant, ability to pay, power and transplant, ability to pay, power and
prestige, or other factors prestige, or other factors
How to deal with a persons desire to be an organ How to deal with a persons desire to be an organ
donor with a consideration for CPR? donor with a consideration for CPR?
Genetic Diagnosis, Engineering, and Genetic Diagnosis, Engineering, and
Screening Screening
Genetic diagnosis: usually done within an in vitro Genetic diagnosis: usually done within an in vitro
fertilization program, a process of biopsy of fertilization program, a process of biopsy of
embryos to determine the presence of genetic embryos to determine the presence of genetic
flaws and gender prior implantation flaws and gender prior implantation
Genetic engineering: ability to alter organisms Genetic engineering: ability to alter organisms
genetically for a variety purpose genetically for a variety purpose
Genetic screening: to determine if persons are Genetic screening: to determine if persons are
predisposed to certain disease, or whether predisposed to certain disease, or whether
couples have possibility of giving birth to a couples have possibility of giving birth to a
genetically impaired genetically impaired
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ETHICAL DECISION MAKING ETHICAL DECISION MAKING
EDM may not seem as clear EDM may not seem as clear--cut as decisions made cut as decisions made
in other areas of life in other areas of life
Jameton Jameton (1984), three types of moral problems: (1984), three types of moral problems:
-- Moral uncertainty, the nurse identifies a moral Moral uncertainty, the nurse identifies a moral
problem but is unsure of the morally correct actions problem but is unsure of the morally correct actions
-- Moral dilemma, two or more mutually exclusive Moral dilemma, two or more mutually exclusive
moral claims clearly apply and both seem to have moral claims clearly apply and both seem to have
equal weight equal weight
-- Moral distress, the nurse knows the morally correct Moral distress, the nurse knows the morally correct
actions and feels a responsibility to the patient, but actions and feels a responsibility to the patient, but
institutional make it nearly impossible to follow institutional make it nearly impossible to follow
through with appropriate action through with appropriate action
ETHICAL DILEMMA ETHICAL DILEMMA
A dilemma exists when a difficult problem seems to A dilemma exists when a difficult problem seems to
have no satisfactory solution or when all solutions to have no satisfactory solution or when all solutions to
a problem appear to be equally favorable moral a problem appear to be equally favorable moral
claims claims
Ethical dilemma occurs when there are conflicting Ethical dilemma occurs when there are conflicting
moral claims moral claims
Conflicting moral claims can occur on between Conflicting moral claims can occur on between
obligations, principles, duties, loyalties, and so forth obligations, principles, duties, loyalties, and so forth
Practical dilemma: situations in which moral claims Practical dilemma: situations in which moral claims
and compete with non and compete with non--moral claims. moral claims.
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ETHICAL DECISION MAKING ETHICAL DECISION MAKING
Similar to the scientific process Similar to the scientific process
-- Defining the problem Defining the problem
-- Identifying objectives Identifying objectives
-- Listing alternative for meeting objectives Listing alternative for meeting objectives
-- Evaluating each objectives Evaluating each objectives
-- Choosing the best alternative Choosing the best alternative
Burkhardt & Nathaniel, 2002
PROCESS OF ETHICAL DECISION PROCESS OF ETHICAL DECISION
MAKING MAKING
1. 1. Gather data and identify conflicting moral claims Gather data and identify conflicting moral claims
2. 2. Identify key participants Identify key participants
3. 3. Determine moral perspective and phase of Determine moral perspective and phase of
moral development of key participants moral development of key participants
4. 4. Determine desired outcomes Determine desired outcomes
5. 5. Identify options Identify options
6. 6. Act on the choice Act on the choice
7. 7. Evaluate outcomes of action Evaluate outcomes of action
Burkhardt & Nathaniel, 2002
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