ENSAYO / ESSAY / ENSAIO

Nursing and the resolution of ethical dilemmas

Enfermería y la resolución de los dilemas éticos

Enfermagem e a resolução dos dilemas éticos

Liliana Basso-Musso¹

¹ RN, M.Sc. Professor, Universidad de Valparaíso, Chile. email: lbassom@hotmail.com.

Receipt date: September 9^th 2011. Approval date: March 23^rd 2012.

Subventions: none.

Conflicts of interest: none.

How to cite this article: Basso Musso L. Nursing and the resolution of ethical dilemmas. Invest Educ Enferm. 2012;30(2): 260-268.

ABSTRACT

Inherent to Nursing Care, ethical dimension includes having to decide about the dilemmas that arise in practice. Experience shows that generally we do not have a reference and then sufficient training to judge the ethical quality of our decisions and actions, reason why, in this article some methods are introduced that will facilitate this ethical analysis when faced with a conflict or dilemma that warrants it.

Key words: ethics; ethical analysis; nursing care.

RESUMEN

La dimensión ética, inherente al Cuidado de Enfermería, incluye el tener que decidir sobre los dilemas que se presentan en su práctica. Generalmente, la experiencia muestra que no poseemos una referencia ni suficiente entrenamiento, para juzgar la calidad ética de nuestras decisiones y acciones, razón por la cual, en este artículo se muestran algunos métodos que facilitarán este análisis ético frente a un conflicto o dilema que así lo amerite.

Palabras clave: ética; análisis ético; atención de enfermería.

RESUMO

A dimensão ética, inerente ao Cuidado de Enfermagem, inclui o ter que decidir sobre os dilemas que se apresentam em sua prática. A experiência mostra que geralmente não possuímos uma referência e depois suficiente treinamento, para julgar a qualidade ética de nossas decisões e ações, razão pela qual, neste artigo se mostram alguns métodos que facilitarão esta análise ética frente a um conflito ou dilema que assim o amerite.

Palavras chaves: ética; análise ética; cuidados de enfermagem.

INTRODUCTION

We should begin by explaining what we mean when we say that our professional acts have an ethical dimension. In general terms, we could say that, while the technical dimension of our actions refers to work well done in terms of its effectiveness, the ethical dimension refers to the goodness and competence of the person who performs the job, i.e., individuals performing this action improve or perfect themselves as individuals by what they do. Thus, this dimension of ethics, inherent to Nursing Care includes having to decide on the dilemmas we face from an ethical perspective. There is no doubt that in Nursing practice we are continuously faced with ethical dilemmas, which sometimes we believe can be analyzed solely through common sense or intuition, but that after pondering over the facts, and the difficulty in finding the best path to its resolution, have shown that they require more than that, and in this search for a resolution, a consensus, a debate, and careful consideration must be employed, focused on complying with the ethical principles intrinsic to a profession whose purpose is the human being with his/her dignity. Experience shows that generally we do not have a reference and then sufficient training to judge the ethical quality of our actions in the nursing practice. This is not so obvious to us. For some, the ethical aspect is not a matter of analysis and will always be implicit in the development of a technique; for others, the scope of ethics belongs by definition to the realm of the subjective, hence, it should not even be necessary to ask ourselves about the existence of objective analysis criteria at this level. There are methods that allow for the development of reasoning and decision-making skills in situations of uncertainty, and that are used to solve these complex problems. The main objective of this article is to show some of the methods for the resolution of ethical dilemmas that have been considered more appropriate to the area of healthcare and that will help to facilitate the difficult task of analyzing these dilemmas ever present in the nursing practice.

Synthesis of content

What are ethical dilemmas? They are problems or ethical issues without apparent solution, which must be resolved in the light of deliberation and analysis or negotiation of differences and ethical points of view to reach consensus on the solution. An ethical problem is distinguished from other problems when: the problem cannot be resolved in isolation by a review of scientific data or details of the situation; when there are two or more ethical values in conflict. The problem is confusing, common sense, logical, or intuition cannot be applied to make a decision; and the answer to the problem will be important and relevant to various human areas;¹ analyzing why more than just common sense is needed, which has been defined as a common knowledge acquired by everybody through the spontaneous exercise of reason, but in a non-reflexive way. The certainties that make up what we call common sense are common to all, so that nobody lacks these, nor can they dispense with them when reasoning. These certainties are few, but absolute and universal. No man can speak and reason without using them as a starting point in his language, and as a logical structure of his reflection on reality, in search of wisdom of any kind. However, common sense is never found in its purest form.

It always relies on the existence of a thought and of a culture.² It is also understood as a skill or the common sense that allows individuals to immediately access the principles, perceptions, expectations, practices, and beliefs common to their society. It is the most basic, primary, and immediate knowledge available to everyone as a member of a community, and this knowledge is also, an essential element to integrate into it. It must be taken into account that the elements of common sense are often not clear or explicit to all members of the community.³ When during human discourse statements compatible with common sense are expressed, these views are in principle acceptable but not enough for the resolution of an ethical dilemma because the latter cannot be generalized.

Considering all the complications resulting from this kind of exceptional dilemma, further, more elaborate information is necessary, along with a consensus of opinions that support its resolution. Another element that could be proposed to solve an ethical dilemma would be intuition. Intuition is the immediate or direct grasping of a reality, or the direct understanding of truth. Claiming to substantiate the ethical by intuition, stresses that although you can argue the existence of emotional insights that provide axiological knowledge, they do not serve as a basis, because in the case of discrepancies there is no criterion to determine what intuitions are correct.⁴ A basic intuition tells us that to morally assess an action it is not enough to describe the external (physical) act performed by a person. Thus, for example, if I invite someone to my home, an outside observer not could decide appropriately on the moral value of my action. This could correspond to an act of beneficence, to pay a wager, or to an instance to assault the guest. It is clear then that to determine the type of moral act corresponding to a physical act; we need additional information that goes beyond mere intuition.

The ethical dilemma appeals to rationality based on ethical principles, and outstrips intuitions as sources to resolve difficulties faced when making decisions and which lie precisely in the opposition between two ideas that may be good; it is not necessarily the opposition between good and evil. This means that to make the right decision, those involved have to think about the most correct because there are no incorrect decisions, and in that sense, people evaluate from the ethical principles, but also, from the results of the action that always considers the moral responsibility compared to the consequences of the acts. Complementing this, Aristotle already differentiated two levels of moral reasoning, one speculative in the form of universal mandates and truth: do good, avoid evil, live honestly; and another one, that attempts to judge as good or bad the particular situations for which there is no certainty and, therefore, no science and which have a coefficient of uncertainty . There is only one way to resolve them: the discussion or effort to make wise and prudent decisions and which has discretion on the particular ethical situations in light of tolerance that is supported by consensus and the common discussion of moral problems.⁵ How could reflection start when there is an ethical dilemma? First, by making sure that you are actually faced with an ethical dilemma. Then, gathering all the relevant information on the case, considering the user's perspective, family, institutional and social aspects. By reviewing and identifying the values themselves, in view of a situation in conflict; verbalizing the problem in a plural debate considering the principles of Ethics of the Discussion. Taking into account the possible courses of action; negotiating the result, which requires confidence in one's individual point of view and respect for that of others, given that the bioethical consensus proposes a methodology to process moral conflict with the same attention to all points of view involved in its resolution. And finally, evaluating the decisions and actions accepted.

Some of the elements of the aforementioned ethics of discussion should be mentioned, its philosophical basis lies in the thesis according to which there is no sense, thought, truth, or value without language.⁶ This was then developed to substantiate Habermas ''communicative action'', whose principles are: recognizing that no moral standard (value) may be excluded from debate, and determining the conditions in which the communicative interaction can take place. These include: its public nature; participation of as many speakers as possible in the debate; the non-limitation of the debate (depending on the necessity or urgency to reach an action and/or decision); equality and freedom of participants in the debate, where relations of authority, domination, or coercion will not have an influence; the principle of argument will govern, i.e., any claim is debatable and the argument that resists all objections is the best; the principle of consensus, where mutual understanding and argued and justified agreement is the purpose and normal termination of communicative interaction. An agreement thus obtained, justifies the decision and the action; and finally, the principle of reviewability; whereby, any agreement must be questionable if new arguments arise.^7,8

Some proposed methods of analysis

It is in the field of decisions from a bioethics perspective, where these dilemmas first appear, seeking to advance research and scientific development.⁹ Bioethics appeared during the early 1970s to defend and improve the living standards of human beings, and especially bound to identify problems of ethical dimension arising in healthcare, as well as the discussions and attitudes that tend to its clarification, management, or resolution.^10,11 Various perspectives and suggested methods facilitate ethical analysis.

Since Beauchamp and Childress. Based on a prima facie analysis of the four principles that are somehow objective and inter-subjective primary duties, and which are morally obligatory, these principles are defined as propositions that establish duties and it is noted that a prima facie obligation indicates that it must be obeyed, unless in conflict on one particular occasion with an equal or stronger obligation. They are then not only prudential maxims, but proposals with a normative nature, which set out the conditions of permissibility, obligatory nature, correctness, or incorrectness of the actions affected or rejected, depending on the case, and, in addition, permanently open to review within their contents and formulations. They do not have a priority order nor can they be prioritized beforehand.¹²

These prima facie principles are: respect for autonomy: a rule mandating respect for the ability of individuals to intentionally make decisions, i.e., tending towards a goal chosen consciously. Defined as personal autonomy, which is the governance of oneself, free of controlling interference by others, and free of personal limitations that prevent wise and understandable choices, for example, improper understanding of information. Autonomous actions are those people perform intentionally tending towards a consciously chosen goal, understanding what they do, free of controlling influences that determine their action. This principle can be subdivided into a set of rules, some of which are: - tell the truth - respect the privacy of others - protect the reliability of information - obtain consent to intervene in patients - when asked for, help others to make important decisions. The paradigmatic expression or the instrument that demonstrates the autonomy of individuals, in healthcare, is informed consent. For this reason, the essential rule that implements the principle of respect for the autonomy of individuals is that which mandates obtaining informed and express consent from patients before applying diagnostic, therapeutic, or research procedures on them.

Do No Harm: a rule mandating to avoid causing damage. It is the duty of not harming others, specified in the following rules: - thou shall not kill - thou shall not cause pain or suffering to others - thou shall not incapacitate others - not offend others - not deprive others of the good things in life. All of these rules have three characteristics: - they are prohibitive rules formulated in a negative way - compliance is impartial, i.e., without exception of people, time, or place - noncompliance usually has legal implications because most of them are already included in the legal standards that are law. The fundamental legal positivization of this principle is that which calls for the requirement of due care to be taken when performing tasks that endanger others. Breaching this legal Do-No-Harm duty is known as malpractice or professional negligence.

Beneficence: a group of standards that provide benefits and weigh them against risks and costs. It is an act done to benefit others. This principle is a normative proposition that forces to act for the benefit of others. Something discussed in philosophy of morality is if you can speak of charities in terms of duty or obligation, or if it would not be better to reduce it to a non-binding moral ideal. For Beauchamp and Childress, obligations of beneficence have degrees. Extreme obligations would not exist, in other words, we would not be obligated morally to help others at all times, even though we are in a position to do so. Such actions fall under the scope of the moral ideals of people, but are not strictly mandatory. However, there is some duty to see for the benefit of others, although it can be divided into a general obligation of beneficence and another specific one. The general obligation is defined as an obligation we have to promote the good of other human beings, where this does not involve a serious disorder in our life plans or major sacrifice. The specific obligation is that arising from specific situations in relation to certain people. Specific obligations would be more binding than general obligations.¹² It can be said that person X has a specific charitable obligation towards Y, if the following conditions are met: Y runs a significant risk of loss of life, harm to his health, or other important personal interests for him. It is necessary for X to work alone or with others to prevent such loss or harm. The performance of X alone or with others has a high probability of preventing such loss and damage. The performance of X does not represent significant cost or burdens. The benefits that Y is expected to receive compensate for the damages, costs, or burdens that X can bear. According to this, some rules may be required: protect and defend the rights of others; prevent damage to others; remove anything that could cause damage to others; help the disabled; save people in danger.

These rules have three characteristics that set them apart from the Do-No-Harm rules, which are: they are expressed positively, given that they endorse certain forms of acting, they need not be followed impartially, i.e., preferences to individuals can be made in complying with them; breaching them does not usually, although with exceptions, imply legal repercussions for the agent. Therefore, the principle of beneficence is involved in two basic dilemmas: that of limits the positive exercise of beneficence sets for nurses; for instance, the problem implicit in the analysis of professional paternalism, and - the exercise of beneficence in the form of the principle of usefulness, i.e., from the perspective of the analysis of costs, benefits, and risks that, should or not be covered by beneficence. From this perspective, it can be indicated that nurses have specific beneficence obligations towards their patients.

Justice: a group of rules to equitably distribute benefits, risks, and costs. There is a situation of Justice when people receive the benefits they deserve for their burdens, based on their particular attributes or circumstances such as being productive or having harmed another. On the other hand, a situation of injustice occurs when an action of erroneous omission denies those benefits to individuals who are entitled to them, or which does not distribute burdens equitably. No one should be treated unequally, despite all the differences he/she may have with others, unless any of these differences is relevant to the treatment being performed. The question is, therefore, to define equality and inequality among people; this is what the material principles of justice are about. They are material principles because they specify the characteristics considered relevant, to decide what form distribution should take. One problem posed by these principles is that there are several and not only one. Throughout the history of the philosophy of morals and politics, six principles have been proposed: to each person an equal share; to each person according to his needs; to each person according to his effort; to each person according to his contribution; to each person according to his merit; to each person according to free market value. Some of the most outstanding conflicts over justice in healthcare are: those of equality in access to healthcare, the right to receive care, distribution of resources for healthcare, and the criteria to ration these.¹³

The bioethics prospect of Diego Gracia.¹⁴ Bioethics principles informed and hierarchical. Diego Gracia wondered ''What does our reasoning use as a reference to make an ethical judgment?'' ''He replies that the reference system is given by awareness of the duty to respect reality as a whole, and within this, to respect human beings in a special way as both substantive and worthy beings''. This consists of two things, on the one hand, to delimit who is really a person, what conditions must he/she meet to be considered as such, if a fetus, an embryo, or someone with brain death are considered as such, and secondly, in trying to explain how to respect people as worthy of being considered as ends in themselves, and treat them with consideration and respect. For bioethics, according to Diego Gracia, the sketch that can possibly best support the reference system is the system of the four principles by Beauchamp and Childress, but introducing some important reforms. In relation to the non-existence of internal hierarchy raised by these in the four principles, Gracia proposes the pre-eminence of the Do-No-Harm and of justice over autonomy and beneficence. The first two make up the first level and the other two the second level.

The first level establishes the moral contents that an ethics of minimums must have, which are the moral contents required of all members of a society, which set the moral minimums below which no one can be placed. All members of a society accept, by means of the procedure of general will, a set of values that will be respected by all, even coercively. The second level sets the contents of the ethics of Maximums, which involve happiness and the self-fulfillment of people. Each person, individually and socially defines his/her own system of values, concept of life, quality and, therefore, happiness.¹⁴

Regarding principles, he has offered some perspectives of how he understands its content:

Do-No-Harm principle: you must treat all persons with the same consideration and respect in the biological order. You must do no harm. Do not be ignorant, unskilled, reckless, or negligent.

Principle of Justice: you must treat all persons with the same consideration and respect in the social order. Do not discriminate individuals because of race, sex, profession, opinion, religion, origin, sex, or economic power.

Principle of Autonomy: you must respect the ability of individuals to knowingly and without coercion perform acts. You must live life responsibly, and answer to your own conscience regarding your particular life project.

Principle of beneficence: do good to another. Seek the greatest possible happiness for another. Seek for others to accomplish their own life projects. Behave as best you can.¹⁵ Bioethics cannot be spoken of without including the moral obligations of nurses because these will always be implied in their professional practice. It has seemed important to show the obligations of staff working in healthcare, in light of how Diego Gracia understands them: the healthcare relationship this staff establishes with a patient has two requirement levels, a minimum below which the crime of negligence is incurred, and another of maximums, which aspires to excellence. In modern bioethics terminology, the first types of duties are known as Do No Harm, and the second as that of beneficence.

The healthcare relationship, being a professional relationship, cannot be satisfied with Do No Harm, but has to aspire to be beneficent. But, as pointed out, the moral obligations of the second level are imperfect duties that each assumes as prompted by his/her conscience, without compulsive imposition, but conversely, professional duties with their consequential moral obligations are freely assumed by individuals in the act of entering their professional activity; therefore, they are no longer of free compliance, but all can and should be demanded to have obligations of beneficence.¹⁶ Thus, nurses have duties of Do No Harm and beneficence, the latter also assumed voluntarily as mandatory, as no one has been forced to practice a profession whose purpose is to care for the health of human beings, and also among its relevant ethical considerations are: respect for the dignity of persons and the obligation to fulfill a series of duties that are morally required, and others such as the Do No Harm, which are legally enforceable.¹⁷

Model adapted from the ''four topics'' method by Albert Jonsen.¹⁸ Consider the following: 1) As a Bioethics referential framework: respect for the dignity of the human being. Hierarchical bioethical principles and ethics of responsibility. 2) Method: Systematization of the case: the present facts. 3) Discussion: Ethical issues of the case: conflict, values, and principles committed. The possible courses of action or implied duties. 4) Resolution of the case: choice of ethically correct, reasonable courses of action. Proposal of recommendations with its foundations. Four topics of analysis would be:

Box 1. Diagnoses and indications (No harm and beneficence) Problems faced when caring for the patient. Prognosis. -Is the problem acute, chronic, critical, reversible, terminal? -Treatment goals. -Probability of success. -What will be done in case of failure? -How will the patient be benefitted and how can damage be prevented?

Box 2. The patient's and family's will (autonomy). What has the patient said? -Has he/she been informed and has he/she understood? -Has he/she consented to treatment? -Is the patient capable? -Are there any previous expressions of will? -If incapacitated, who subrogates him/her? -Does the patient not cooperate with the treatment why? -Is the will of the patient being respected to the extent possible?

Box 3. Quality of life; goals to achieve (Usefulness and Proportionality) Probability, with and without treatment, to recover previous quality of life. -Is there bias in the evaluation of quality of life made by the professionals? -What mental, physical, or social deficit can result after the treatment? -Can the present or future condition be considered undesirable? -Are there plans to limit treatments? -Are there support and palliative care plans?

Box 4. Context (Justice). Are there family events that influence decisions? -Do medical or healthcare team interests influence? -Are there economic factors? -Are there religious or cultural factors? -Are there problems of resource allocation? -Are there legal implications in decisions? - Is it is a research case? -Do healthcare professionals or the institution have conflicts of interest?¹⁸

Paulina Taboada model applied to Nursing.¹⁹ It includes six points:

1. Identification and description of the problems or ethical dilemmas with a wording of the relevant questions, in an operational mode that allows giving precise answers:-reference to basic concepts that will define the ethical dilemmas involved. E.g.: terminally ill patients entering an intensive care unit. -Operational Description: Identification of ethical issues by Nursing, considering clinical aspects and relevant background in an assessment. E.g.: must the parenteral administration of the treatment be continued? -Identification of the object, purpose and circumstances of moral acts: object: Fact around which the reflection or discussion will develop. Answer to the question: what are you doing? Does not designate the ''neutral object'' of the physical act, but the content of the will of the agent. It corresponds to the intention of the act. E.g.: continued parenteral treatment on a multi-punctured patient in terminal phase. Purpose: intentionality of the act: what? Why does he do it? For what reason? Designates that in light of which the act is performed. It corresponds to the intention of the agent; traditionally called ''purpose of the operator or Finis operandi''. Circumstances: Designates the specific determinations of an action or the circumstances surrounding it: time, place, and manner. The circumstances surrounding my act are determinants of its moral quality.
2. Analysis of the ethically relevant clinical information:-Certainty of the medical and nursing diagnoses - Prognosis of survival - Patient competence - family and social support network.
3. Reference to ethical and legal principles involved: Charitable, Do No Harm, justice, autonomy, responsibility, dignity, confidentiality, truthfulness, human rights, law, other. -What is the predominant principle? Order from the most complex or related to the more immediate and necessary to be resolved.
4. Evaluation of the action alternatives action and their results: - Benefits and alternative risks - Morbidity - Mortality. -Costs: physical, psychological, economic, social, and spiritual.
5. Resolution of the problem: -who must decide. -What aspect of the decision falls directly under the nurse's responsibility. -Competence or capacity of the patient and or his/her family to participate actively in the decision-making process.
6. The practical implementation of the solution: Who? When? How?

CONCLUSIONS

It would be naive to think that with a system of principles or a method, whatever the case, we can solve all the moral problems.²⁰ Principles must be general by definition, and ethical disputes are private. In the field of bioethics, tradeoffs hinder the adoption of decisions. Each case, especially in the field of nursing, is different and what will be the right decision cannot be determined in advance. In every situation, it is imperative to carefully analyze the relevant data because no matter how similar a situation is to another, new variables always appear, and consider the consequences of the act or decision. Ethics should serve to assess, study, and analyze the relationship between empirical data derived from specific situations of reality in which human beings live and die.²¹ Despite this, true professional ethics requires a systematic approach that leads to moral discernment, as well as to decisions that are successful, which also provides an appropriate framework to adopt ethical decisions, which ensures that they are taken in consideration of the relevant data by clarifying rights and responsibilities, and to ensure an increasingly distrustful society, where decisions important to patients and their families have been taken after due reflection.

The process to analyze ethical issues, especially ethical dilemmas, often becomes a process of negotiating differences. The healthcare team is multidisciplinary, regardless of where the person may be in the welfare-illness continuum. When ethical dilemmas arise, the points of view of nurses, the user, the family, and the health team, play an important and vital role. In summary, models exist that can provide a procedure that may be used for ethical decision-making in the nursing and healthcare fields. All useful modern methods basically include analysis of medical, human, ethical, and economic factors in each case. Each model has advantages and disadvantages, the nursing professional will decide which yields the best results and how it can be improved it to make it more viable.

Finally, it can be concluded that within the moral reasoning process regarding cases considered ethical dilemmas, at least six steps should be considered for analysis: description of the facts of the case, be sure to investigate every fact even if it is not directly present in the case, as long as it is relevant to its solution. Description of values (goals, interests) of all parties involved in the case: doctors, nurses, patients, family, hospital staff and individuals from society. The main conflict of values or which of the core values are threatened. -The determination of possible measures that could protect the broadest possible number of values in the case. -Consensus on the choice of a way of acting. -Defense of the decision from the values underpinning it. Nurses can and should offer their perception and their expertise to solve ethical problems, within the context of family and staff meetings, and other situations. For Nursing, resolving an ethical problem is similar to the process of nursing.²² Systematic and careful reasoning is required. The only difference with the latter is that the ethical dilemma requires: negotiation, incorporation of conflicting ideas, and an effort to respect differences.

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