One Way to Analyze and Construct an Argument about the Ethics of Nursing Action in a Specific Situation

Students frequently give arguments about right action, but when you press them to say why they think something is not good or right or is good or right, they will answer, with some degree of incredulity that someone would be asking such a question, that "It just is". This way of thinking about and discussing ethics with others isn't always very convincing (convincing others is one goal of ethical discussions), unless the person you are talking to happens to already agree with you. Being able to say why we think that something is good or right in a way that we can change others thinking and have our thinking changed allows us to learn more about right and good action than we already know. Here is an example of how to One way to decide (analyze) the ethics of a situation is to ask
  1. "What values are being served and not served in the actions taken by the nurse?" and then
  2. "What values are the good and right values that ought to be served in the situation by a nurse's action?"

Situation

I will use an example given by a student in her journal. She wrote about a patient who was left for some time in a room with the dead body of his roommate. She said that the living roommate kept looking and staring at the curtains which hid the body (apparently the curtain was drawn). He asked the nurse repeatedly when the body would be moved. However, when asked if he was being made uncomfortable by the body of his roommate, the living roommate replied that he wasn't bothered.

The student wondered whether the roommate had in fact been the only one to have observed the actual death. Apparently, the dying roommate was breathing loudly. The patient was concerned about the breathing and probably was the only person in the room when the breathing stopped and the student thought that it was probably the roommate who notified the nurses.

The student believed that there was a clear discrepancy between the living roommate's behavior and his words about being bothered by the presence of the body, and she raised the question of the ethics of keeping a patient, who happens to be the roommate of a dying patient, in the room through the dying patient's death process and then with the body until the staff, who may be very busy, can prepare the body for transport. In this case, a potential complicating factor was that the living roommate was also at risk for dying (71 years old).

Values Being Served

It is clear that some of the values being served by the nurse's actual actions (she did not move either the roommate or the dead body immediately) were One thing that we do know is that the death of person is a frequent occurrence for nurses and when a patient dies nurses tend to see the preparation of the deceased's body as a task to be accomplished and prioritized in relation to the many other (and often more immediately important) life-promoting activities they are also obligated, both professionally and institutionally, to perform.

Values Not Being Served

However, we also know that some values were not being served in the nurse's determination of appropriate action. These were To argue that these should have been served. we need to examine the specific manifestations of these values in the situation more closely.

Conclusion

Many important values were not served by the nurses action. It is not clear that the values being achieved and the values that needed to be achieved contravene each other. Therefore, other means of caring for dying patients that address these additional values ought to be sought by nurses and nursing institutions. The nurse in this situation should have transferred the dying patient to a private room when she believed the death process had began. Given that she did not do this, she should have called the nursing shift-supervisor and gotten personnel resources to stay with the roommate until the body could be removed. She should also have tried to get the resources to have the body removed immediately. In addition she should have spent time with the roommate debriefing him about his concerns and feelings, having witnessed this potentially traumatic event. Further, she needs to raise this problem with the institution and to work with them to find ways to care more ethically with patients in the throes of death processes and to find ways to care for dying patients in the interim that address the values outlined. Of course, in particular situations it is sometimes impossible to achieve all the values that ought to be achieved and there are often many perspective about what the important (good and right) values are in a situation. When the actions that are needed to achieve the set of values that are considered good and right in a situation contradict each other, deciding which values to actually achieve in a situation is called an ethical dilemma because achieving one value often means one cannot achieve another. In these cases one has to decide which combination of values are most important, or which ones realize the greatest good. Another strategy is to try to minimize the harm and maximize the good. However, in these situations, perhaps what is most important in ethical practice is to try to create, after encountering a dilemma, new conditions so that the dilemma doesn't arise too often. In this situation, the nurse may have been facing a dilemma and acted to meet what she thought were the most critical needs of the patients on her floor at the time. Often however, action is not a conscious response to a real ethical dilemma, but is based merely on the fact that one has not realized that important values were being omitted in how one decided to act. If the problem of how to care both for dying and living patients is an ethical dilemma, the nurse needs to work with others to find ways to solve the delivery-of-care problems that are creating the situation where important values are incapable of being met. If the problem is one of lack of careful attention to the question of what values are not being achieved, merely realizing them and attending more to them can improve care. Certainly, in every situation some action can always be taken to make conditions better in the future.

Another argument is also worth considering. Often students say that they do not have the time or the option to consider the ethics of their action in practice and that their actions are dictated by hospital policy. For example it is sometimes hospital policy to have patients share a room.

Ideally, hospital policy is a code for right and good action. However, it is often limited in scope, incomplete and may even be misguided. Institutional culture also guides action and affects hospital policy. Neither are complete guides to right and good action. Further, hospital policy and institutional culture develop from practice and theory and change as 1) the actions that these systems of conduct sanction are tested critically in practice, 2) constructive evaluations of the policies in practice are shared with the policy makers and peers and 3) efforts are made by everyone to find ways to improve both the policies and norms and how they are practiced. It is everyone's obligation to work together to improve not just the science but also the ethics of practice. Sometimes these problems seem overwhelming, but this does not mean that it is good and right to ignore them. One might also keep in mind that an ethical problem often arises in solving other difficult ethical problems in how one acts towards others. One might argue that ideally everyone should try to act towards each other in ways that also realize good and right values and principles such as goodness, kindness, and respect for autonomy.

Application of Reading.

Students self-selected readings do not have to bear directly on the problems they discuss each week. However, they must still say how their reading affected their thinking about the situation they discuss. To show one way to do this, I read Robert Cavalier's section from his ethics course on the Right to Die, which is not directly related to the problem I addressed above. He outlines five elements that must be present for an act of killing to count as euthanasia. These boil down to a) one must make an act of commission to bring out death, 2) the patients condition must be such that he would die relatively soon anyway, 3) the patient must be experiencing terrible pain, 4) the patient must ask to be killed, and 5) the killing must be an act of mercy done to alleviate the suffering. One question I have is "Is the question 'Is it right to take life to prevent extreme suffering?' of the same form and status as the question 'Is it right to force ill patients to witness others' deaths?'." That is: "Are these both moral questions?" I also read "Hospitals, Nurses, and the Social Organization of Ethics: Beyond Caring" by Chambliss. He suggests
  1. that ethical problems are distinguished by conflicting moral principles that must be resolved by an individual practitioner in order to decide what personal action she or he should take in a particular situation and
  2. that what are often characterized by nurses as ethical problems in practice are not "classical" ethical problems but "practical, debatable issues of politics" that result when the values of groups or individuals come into conflict.
This causes me to ask "What counts as an ethical problem?" and whether what I have written about (and also what Cavalier characterizes as an ethical problem in his section on Euthanasia, are ethical problems. I think that both are ethical problems. Both address the question of right action, both address conflicting moral principles (in the dying situation these might be "Do the greatest good for the most people" versus "Protect an individual from an extremely painful event". I think that Chambliss is too narrow in restricting ethical problems to problems of conflicting values within an individual deciding how to act in a particular situation. The latter certainly can be characterized as an example of an individual "moral dilemma". But not all ethical questions are reducible to questions of individual moral decisions or even moral dilemmas. For example the question of "Should I keep slaves" is not necessarily the same as the question of "Is it right to keep slaves?" Yet both are ethical questions --- questions of the right and good action.

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