Ethics 2024 PDF

Ethics Exemplars: Ethical decision making in practice – beginning of life (minor consent), Decisional capacity, Pain management and addiction, Involuntary Psychiatric Treatment Act Rebecca Jones MN, RN, GNC(C) NRSG 3101 Minor revisions by Emily MacLeod – Fall 2024 What is “ethics”? Ethics is a...

Ethics Exemplars: Ethical decision making in practice – beginning of life (minor consent), Decisional capacity, Pain management and addiction, Involuntary Psychiatric Treatment Act Rebecca Jones MN, RN, GNC(C) NRSG 3101 Minor revisions by Emily MacLeod – Fall 2024 What is “ethics”? Ethics is a branch of philosophy that is concerned with human conduct. It examines the rational justification for our actions or inactions; and judgments of what is right or wrong, just or unjust. Ethics encompasses many different dimensions of a person’s life. Government of Canada, 2015 Societal Ethics Society provides a normative basis for ethical behavior with laws and regulations. “Law” is defined the minimum standard of behavior to which all members of society are held. In nursing, legal standards include:  Clinical standards of care  Liability  Negligence  Malpractice Organizational Ethics Formal and informal principles and values that guide the behavior, decisions, and actions taken by members of an organization Directs all aspects of an organization Professional Ethics Ethical standards and expectations of a particular profession (e.g. nursing) Held to a higher standard because of privileged role in society Code of conduct Aimed at the highest ideals of practice Bioethics/Clinical Ethics/Research Ethics Bioethics: Ethical questions surrounding biological sciences and technology Clinical ethics: Decisions made at the bedside Research ethics: Part of bioethics; conduct of research using humans and animals Personal Ethics Personal ethics refers to the moral principles and values that guide an individual's behavior and decision-making. These ethics are shaped by a variety of factors, including cultural, social, religious, and personal beliefs. Personal ethics serve as a framework for distinguishing right from wrong and guide individuals in their interactions with others and their choices in different aspects of life. Continuously intersect with the other categories of ethics. Do not overlap perfectly; consequently, a potential for conflict exists* Sources of ethics are not static and change over time Morality vs. Ethics Morality – an accepted set of social standards or morals that guide behavior. Ethics – deals more specifically with the concepts of right and wrong. *Morality is a broader term* Can we be 100% “ethical”? Achieving absolute or perfect ethics is a challenging proposition for several reasons. While individuals strive to be as ethical as possible, there are inherent complexities and ethical dilemmas that can make it difficult to achieve complete ethical consistency. Here are a few factors that contribute to the challenge… Factors that contribute to our “ethical challenges” 1) Ethical dilemmas: Life often presents situations where ethical principles can conflict with each other. These dilemmas may arise when one must choose between two or more ethical values that seem equally important but are incompatible. For instance, the ethical principles of honesty and loyalty may clash when an individual is torn between telling the truth and protecting someone's feelings. Resolving such dilemmas can be complex and may require weighing different ethical considerations. 2) Limited knowledge and information: Ethics often relies on accurate and comprehensive information. However, individuals may lack complete knowledge or understanding of a situation, making it challenging to make fully ethical decisions. Additionally, new information or changing circumstances can influence the ethical assessment of a situation, leading to potential revisions of ethical judgments. 3) Cultural and contextual differences: Ethical standards and values can vary across cultures, societies, and individuals. What may be considered ethical in one cultural context might be viewed differently in another. These differences make it challenging to define a universal set of ethical principles that apply to all situations and people. 4) Personal biases and subjective judgment: Individuals are prone to biases and subjective judgment, which can influence ethical decision-making. These biases can cloud objective ethical reasoning and lead to inconsistencies or deviations from ethical principles. Basically… While achieving absolute ethical perfection may be challenging, individuals can still strive to be as ethical as possible by continuously examining their values, seeking knowledge, and reflecting on the ethical implications of their actions. It is important to engage in ongoing self-reflection, learning, and openness to ethical discussions in order to refine and improve one's ethical conduct. The aim should be to consistently align one's behavior with ethical principles while acknowledging the inherent complexities and limitations that may prevent attaining a perfect ethical standard Ethical Conflict Moral Distress Moral distress  Unable to act in a morally appreciated way  Being forced to act contrary to your personal and professional values Situations causing moral distress:  Similar to ethical issues  End-of-life situations When exposed to this situation, it may result in frustration, anger, guilt, anxiety, withdrawal, self-blame, and other stress-related symptoms. Let’s pause and think for a moment… As nurses, when we are confronted with difficult choices, how we act ethically in practice? Four-Principles Approach to Ethical Decision Making Jonsen et al. framework Provides a systematic approach to ethical decision-making in healthcare settings and is often used to analyze ethical dilemmas and guide ethical reasoning. The framework is based on four core principles: 1. Autonomy 2. Beneficence 3. Non-maleficence 4. Justice 1. Autonomy Autonomy refers to respecting an individual's right to make their own decisions and choices. In healthcare, it emphasizes the importance of informed consent, patient autonomy, and respecting individuals' rights to make decisions about their own bodies and healthcare. This principle recognizes the individual's right to be involved in the decision- making process and to have their values, preferences, and wishes respected. 2. Beneficence Beneficence is the principle of doing good and promoting the well-being of others. It involves taking actions that benefit others, promote their welfare, and enhance their quality of life. In healthcare, this principle guides healthcare professionals to act in the best interest of the patient, ensuring their well-being, and providing care that maximizes benefits. 3. Non-maleficence Non-maleficence is the principle of avoiding harm or minimizing harm to others. It emphasizes the duty to do no harm and to prevent or minimize risks and potential negative outcomes. In healthcare, this principle guides healthcare professionals to prioritize patient safety, avoid unnecessary risks, and carefully balance the potential benefits and harms of medical interventions. 4. Justice Justice refers to fairness and equity in the distribution of resources, opportunities, and access to healthcare. It involves treating individuals fairly and equally and addressing social and structural factors that can lead to healthcare disparities. This principle considers the allocation of limited resources and aims to ensure fair and just distribution of healthcare services and benefits. The key is asking quality questions using Jensen et al’s framework. Think about these questions when faced with an ethical decision/dilemma: Do I have a duty to tell the truth? What is the greater harm? To whom is my primary loyalty? What are the best interests of my patient? Reflective Exercise A patient refuses blood transfusion at the point of death because of his religious belief (Jehovah's witness). Would you go ahead and transfuse him anyway based on the knowledge that he is the father of six children who will suffer greatly when he dies? Ethical Issues in Nursing Protecting patients’ rights and human dignity Respecting or not respecting informed consent treatment Providing care with risk to the health of the nurse Using or not using chemical or physical restraints Staffing patterns that limit care (understaffing) Prolonging the living/dying process with inappropriate measures Not considering the quality of the patient’s life Policies that could threaten the quality of care Working with unethical or impaired colleagues Exemplar: Ethical decision making in practice – beginning of life (minor consent) Consent is: “the patient’s ability to understand information relevant to a treatment Coughlin, 2018; Canadian Paediatric Society, Bioethics decision and to appreciate the reasonably foreseeable consequences of a decision or lack of decision” (Osborne, 2013). 1. No mutually agreed, legally defined age of consent in Canada 2. The capacity of young children to consent to treatment varies with age, and their prevailing health circumstances 3. If the young children is incapable, informed consent process requires that a capable decision-maker be given all relevant information that a Committee reasonable person would require to make an informed decision. Minor Consent and Care Providers Care providers of children health care are required to make assessments, keeping in mind: The context of the patient’s emerging self awareness, developing values and beliefs, and maturing cognitive skills Provincial/territorial laws determining the age of majority or consent In situations where capacity is not demonstrated, legal decision-making authority rests with the SDM, who is required to act in the best interests of the child. Age of Consent In Canada, the ability of children to provide consent for medical treatment varies depending on their age and capacity to understand the nature and consequences of the treatment. Here's a general overview of the consent laws regarding medical treatment for minors in Canada: 1. Mature minors: Some provinces in Canada, such as British Columbia, Alberta, and Manitoba, have legislation that allows "mature minors" to provide consent for their own medical treatment, regardless of their age. The term "mature minor" refers to a minor who has demonstrated the capacity to understand the treatment's nature, consequences, risks, and benefits. The healthcare provider assesses the minor's maturity and decision-making ability on a case-by-case basis. 2. Age of consent: In other provinces and territories, the age of consent for medical treatment without parental involvement varies. For instance, in most provinces, including Ontario, Quebec, and Nova Scotia, the age of consent for medical treatment is generally considered to be 16 years old. This means that individuals who are 16 or older can provide consent for medical treatment without parental involvement. 3. Younger children: For children under the age of consent, parental or guardian consent is typically required for medical treatment. Parents or legal guardians are responsible for making medical decisions on behalf of their minor children and providing consent for their treatment. However, there are exceptions in cases of emergency or situations where immediate treatment is necessary to prevent serious harm or save the child's life. In such cases, healthcare providers can provide treatment without parental consent. Age of Consent & Sexual Assault 16 and 17-year-olds cannot consent to sexual activity with whom they have a “relationship of trust, authority, or dependency” or where there is “exploitation” (e.g. a coach, doctor, or teacher). 14 or 15 can consent to sexual activity with someone who is less than 5 years older but it cannot be a “relationship of trust, authority, or dependency” or where there is “exploitation”. 12 or 13 can consent to sexual activity with someone who is less than 2 years older but it cannot be a “relationship of trust, authority, or dependency” or where there is “exploitation”. Under 12: cannot legally consent under any circumstance. Someone cannot legally consent to sexual intercourse with their parent, child, sibling, grandparent or grandchild. This is incest. Case Study – Josh Exemplar: Decisional Capacity Decisional capacity can be defined as the ability of people to make their own: medical decisions capacity to stand trial in a court of law ability to make decisions that relate to personal care and finances Hawkins, 2020 Elements of Capacity Choice Understanding Appreciation Reasoning Personal Directives Act (2008) & Regulations PDA: allows an individual with capacity to make a personal directive outlining instructions about their future personal care decisions to be made on their behalf in the event they lose capacity. Personal care: “health care, nutrition, hydration, shelter, residence, c, hygiene, safety, comfort, recreation, social activities, support services and any other personal matter that is prescribed by the regulations”. Delegate: a person authorized under the personal directive to make, on behalf of the maker, decisions concerning the maker’s personal care. NSCN, 2018 This must be signed, in writing, and witnessed Adult Capacity and Decision-Making Act (ACDMA) Incompetent Persons Act → ACDMA and Regulations (came into effect Dec. 28, 2017) Guardian → representative For adults who may not be able to make their own decisions (e.g. mental health, learning disability, acute brain injury, etc.). Authority to conduct a capacity assessment extends to:  Physician  Psychologist  NP and RN with completed education Nurses’ Accountabilities Related to Assessing Capacity under the PDA and ACDMA Familiarize yourself with the specific legislation that is applicable to their practice setting and the type of capacity assessment required as well as to follow agency policies when initiating an assessment of capacity: If the nurse believes the individual has capacity, the nurse obtains consent from the individual and provides the nursing service or treatment. If the nurse is unable to determine the individual’s capacity to make personal care decisions, they should consult the individual’s primary care provider to request further assessment. If the nurse is aware that the individual has an enduring power of attorney or a personal directive, the nurse should inform the primary care provider as part of the consultation. NSCN, 2018 Nurses’ Accountabilities Related to Assessing Capacity under the PDA and ACDMA If there is disagreement about the individual’s capacity or when requested by a delegate, statutory decision-maker or others as outlined in the PDA or ACDMA, the nurse should request an assessment of the individual’s capacity by an authorized health care professional. Where a determination has been made that the individual does not have capacity, and a personal directive exists, the nurse should follow the instructions of the personal directive and/or the directions of the delegate named in the personal directive. When a decision has been made that a client does not have capacity and a personal directive does not exist, the nurse must seek out the statutory decision-maker to make informed decisions on the client’s behalf. NSCN, 2018 Exemplar: Pain Management & Addiction Pain is subjective, quantifiably unmeasurable, involves trust, depends on patient and provider values, and requires a moral agent for assessment and treatment. The management of pain is an ethical undertaking and requires a moral framework. Is there a moral obligation to treat pain? Or prevent addiction? Or both? Reflective Exercise Is it ever ethically permissible to allow pain to continue untreated? Are people who complain that pain is ongoing manipulative or lazy? Do individuals with decision-making capacity have a right to treat their own pain as they choose? If a choice has been made, is it more morally acceptable to treat pain or treat addiction? How do I know that someone is telling the truth about their pain? Exemplar: Involuntary Psychiatric Treatment Act (IPTA) In October 2005, the Nova Scotia House of Assembly passed the Involuntary Psychiatric Treatment Act (IPTA). The Act is about making sure that those who are unable to make treatment decisions, due to their severe mental illness, receive the appropriate treatment. Pre-conditions for involuntary admission include: An individual is threatening or attempting to be or has recently been a danger to him/herself or others; or is likely to suffer serious physical impairment or serious mental deterioration or both; lacks capacity to make decisions about his or her care, requires care in a psychiatric facility and cannot be admitted voluntarily. Reflective Exercise Does an involuntary psychiatric admission violate the patient’s fundamental rights? Case Study – Social Media