Archive for the ‘ethics’ Category

Here’s an interesting story from The Telegraph: Psychiatrists and nurses admit lying to dementia patients.

Truth-telling is one of the ethical pillars of modern healthcare. Telling patients the truth is generally seen as a key part of treating them with respect. Lying to them is a form of manipulation that is usually incompatible with respecting patient autonomy.

Are patients with demential an exception? Certainly it’s hard to make a case for a blanket exception, given the enormous variation in cognitive capacities and emotional states that can fall under the general heading of “dementia.” It may well be that there are a limited number of particular circumstances with particular patients in which lying is justified. But nurses should never be complacent or come to think that lying is part of standard care.

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Ethics of Accepting Gifts from Patients

Should healthcare professionals accept gifts from patients? Small gifts? Big ones? How about multi-million dollar gifts?

That’s the topic tackled in this opinion piece by bioethicist Art Caplan: Heiress’ gifts to medical workers raise thorny ethical issues.

The gifts in question in the case Caplan discusses are very large indeed. Most health professionals will never have to give serious consideration to the ethics of accepting a million dollar gift. But thinking through the ethics of a case like this one is a good way to focus discussion on the principles behind the need to maintain boundaries.

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Nurse-patient ratios probably aren’t discussed in most nursing ethics classrooms. But it’s clearly an ethical issue. Check out this recent story out of Massachusetts:

Mass. Nurses Association demands mandatory nurse-patient ratios

The trade group representing nurses is pledging to put the “sweat equity” of its 23,000 members behind a push to impose statutory nurse-to-patient ratios, but hospital officials are decrying the proposal as running counter to the trend toward a health care system where providers are reimbursed based on the quality of care they deliver and patient satisfaction.

The Massachusetts Nurses Association on Monday outlined plans to press for passage of a 2014 ballot proposal if the Legislature does not act by the middle of next year to pass nurse staffing legislation, which would apply to acute care hospitals.

The proposal calls for one nurse for every four patients in medical/surgical units….

It’s clearly a complicated issue. Nursing ratios are of course crucial to patient care, in general, but I suspect it is very hard to describe a one-size-fit’s-all solution, which is more or less what regulation would require.

Note also the difficult challenge, here, from the point of view of responsible advocacy. The MNA wants to advocate from the point of view of patient safety, which is entirely appropriate. But any attempt to legislate nursing ratios will of course be perceived by some as an attempt to maintain employment levels for nurses.

Finally, note that this issue raises questions of interdisciplinarity and the role of allied health professionals. In some cases, nurse ratios are being reduced because nurses are being replaced (or supplemented) with other kinds of workers. Sometimes that will be a very bad thing (for patients). Sometimes that will probably be a good thing (for patients). Sorting out which is which is a significant ethical challenge.

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Former Australian arts minister, Ros Bates, is facing criticism (and potential parliamentary censure) for claiming to be a Registered Nurse, when she had in fact allowed her license to laps.

It’s a bit of a tempest in a teapot. Bates is probably right that, in the context of parliamentary debate (rather than, say, in the context of being hired at a hospital), critics are “nit-picking” when the point to the difference between being a qualified nurse and being a registered nurse.

But the story is a good reminder of the social privilege that licensure implies. Compare: I’m a philosopher by training (that’s what my PhD is in). But no one ever gets in trouble for “falsely” claiming to be a philosopher!

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Discrimination Against Nurses

This one isn’t really about nursing ethics, though it has plenty of implications for the ethics of nurse managers.
Hospital settles nurse’s discrimination suit.

After settling one lawsuit, a second was pending Friday against a Flint, Mich., hospital accused of honoring of a swastika-tattooed man’s request that African-American nurses not care for his newborn….

My main comment: The “customer” isn’t always right.

But fodder for discussion: what can (or do) hospitals do to handle such problems? What can or should they do when patients express preferences that are clearly discriminatory?

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From PBS: Next Health Care Mandate: Flu Shots for Medical Workers?

Brandon Hostler’s arm is usually among the first extended for the annual flu shot at Ruby Memorial Hospital in Morgantown, W.Va. He is, after all, a registered nurse — he knows it can do some good.

But if that shot ever becomes mandatory, he will balk.

“I wouldn’t quit or switch jobs,” he said. “But we are health care professionals. We know the risks and the benefits, and to force us to do something like that and not have a say in it, I think it would be offensive and unwanted.”

This story nicely points out two different facets of one of the most important values in the world of healthcare, namely autonomy.

Why is autonomy important? On one hand, it is important for its own sake. We simply value the ability to choose for ourselves. On the other hand, we value autonomy because we generally believe that when people choose for themselves, they will choose better than when others choose for them. Both of those facets of autonomy appear in the story above. Some nurses are hesitant about the flu shot because they’re uncertain about whether the risks are worth the benefits; others think the benefits are there, but still want the freedom, for its own sake, to say “no thanks.”

But there are also limits on autonomy. And in particular, membership in a profession brings a whole bunch of such limits. The benefits of professionalism involve a kind of quid pro quo — society asks things in return. The hard question, of course, is whether any particular limit on autonomy — such as mandatory flu shots — is or should be part of that bargain.

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When is unethical behaviour by a nurse not a matter of ‘nursing ethics’?

From the Wisconsin State Journal: “Nurse disciplined for using donor program credit card for personal use”

A registered nurse who used a Neenah hospital’s organ donor program credit card to take cruises and vacations with her husband has been disciplined by the state Board of Nursing.

The board suspended the license of Peggy Grambsch, of Poy Sippi, for six months on Jan. 26. It also ordered Grambsch to take a nursing ethics course and pay $750….

It’s hard to blame the board for requiring that Grambsch take an ethics course. But it’s hardly likely to be the right remedy here. First, the behaviour she engaged in is, as far a I can see, a matter of outright criminality, rather than subtly unethical behaviour. Secondly, to the extent that there are ethical issues here — misappropriation of funds is of course unethical, in addition to being illegal — I suspect such issues are not covered in most nursing ethics courses. If I were on that board, I would have insisted on a business ethics course, especially one with a section on financial integrity and ethics in the workplace.

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Compassion Fatigue

Who cares for the care-givers?

From the Wall Street Journal: Helping Nurses Cope With Compassion Fatigue

New programs are underway to help nurses cope with compassion fatigue, an occupational hazard for caregivers that also puts patients at risk of substandard care….

Though the intense emotional demands on nurses are as old as the profession itself, researchers have only in recent years begun to study the effects of compassion fatigue, a form of burnout compounded by secondary traumatic stress….

It’s good to see that this article discusses the impact of compassion fatigue not just on nurses, but also on patients. But of course, while impact on patient care is the ‘trump card’ of the world of healthcare, it shouldn’t be forgotten that institutions of all kinds have a fundamental obligation to safeguard the mental and emotional health of employees.

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A recent book review in the Chronicle of Higher Education highlights the most recent work of neuroscientist, philosopher and author Patricia Churchland, who offers some interesting views on modern day morality, in her new book Braintrust: What Neuroscience Tells Us About Morality(Princeton University Press)

Here’s an excerpt from the Chronicle review of Churchland’s book: Rule Breaker: When it comes to morality, the philosopher Patricia Churchland refuses to stand on principle

Hers is a bottom-up, biological story, but, in her telling, it also has implications for ethical theory. Morality turns out to be not a quest for overarching principles but rather a process and practice not very different from negotiating our way through day-to-day social life. Brain scans, she points out, show little to no difference between how the brain works when solving social problems and how it works when solving ethical dilemmas.

Churchland thinks the search for what she invariably calls "exceptionless rules" has deformed modern moral philosophy. "There have been a lot of interesting attempts, and interesting insights, but the target is like perpetual youth or a perpetual-motion machine. You're not going to find an exceptionless rule," she says. "What seems more likely is that there is a basic platform that people share and that things shape themselves based on that platform, and based on ecology, and on certain needs and certain traditions."

The upshot of that approach? "Sometimes there isn't an answer in the moral domain, and sometimes we have to agree to disagree, and come together and arrive at a good solution about what we will live with.”

The point I found most interesting, reading the review, was that Churchland feels that the emphasis on finding "exceptionless" moral rules is futile. According to her, we should place more emphasis on how we can agree to disagree rather than consistently search to find "exceptionless rules" to apply in difficult moral dilemmas.

She makes a good point and one that many of us should consider. Think of the many times we are faced with moral dilemmas in the context of nursing. Often the most effort goes into attempts to make others see situations from our perspective, and to agree with us. Frequently we hear statements like, "This should never happen" or "We should not allow this in any case" when our colleagues, patients and families are discussing difficult moral issues, like end-of-life care or allocation of scarce resources. These kinds of expressive statements, such as "I believe X is wrong" (instead of “X”, substitute any contentious bioethics concept such as: abortion, euthanasia, harm reduction), reflect a kind of "exceptionless" stance. When we approach difficult moral dilemmas with this kind of a stance, we typically are, in fact, looking for others to agree with us and align with our values to justify an "exceptionless rule" of sorts. However, it's clear that this is almost impossible in diverse societies and groups in which a broad range of values exist.

We accept diversity in many kinds of everyday health care situations and out of that acceptance arises our role of advocate and facilitator. For example, a patient may not wish to take a prescribed sleep aid, may refuse physiotherapy or may wish to delay a procedure. As nurses, we advocate for the choices and wishes of our patients and we try to facilitate their decision-making. We often allow patients to make choices that we perhaps would not make ourselves or that we would not support if we were the only decision-makers. This is part of respecting the autonomy of others and is a straightforward value in nursing and health care. However, when dealing with more difficult or challenging dilemmas, we tend to turn first to our own values and beliefs instead of first trying to consider the different values of others. This isn’t unusual and is a response many have when faced with morally challenging situations: we turn to our own consistently-held values and beliefs in a search for an anchoring answer. In other words, in simple day-to-day health care situations, we often quite easily accept that patients will make choices that reflect different values and beliefs than ours and in turn, we respect those diverse decisions. In more serious or morally challenging situations, however, we may find ourselves turning instead to our own values and beliefs to determine what the “right” option should be.

Churchland notes that trying to find answers to difficult moral problems is just like trying to find our way through less challenging, day-to-day social problems. As she notes, brain scans show very similar activity when sorting out everyday problems or working through serious and difficult moral dilemmas. For many of us, it is perfectly acceptable to “agree to disagree” on the food a patient may eat, the time for a procedure to be done, scheduling therapy or taking a sleeping aid. However, when faced with a patient who is, for example, seeking euthanasia or an abortion for a reason with which we may not agree, many nurses find it disturbing, upsetting and often distressing to care for patients whose values and beliefs, in this context, may be much different than their own. Churchland would likely say that trying to seek alignment of values, in difficult cases like this is neither satisfying or possible and that we should not focus so much attention on trying to do so.

The review in the Chronicle is a thorough one, highlighting a number of other key points in Churchland’s work. I haven’t read the book yet so it’s difficult to comment too much on her views, as noted by the reviewer, without reading about them firsthand, so I will read the book and, hopefully, will review it here as well.

The point that struck me was that we don’t really think enough (or at all!) about how we approach moral dilemmas. In nursing, these kinds of dilemmas arise often unexpectedly or quickly and must be dealt with in the moment. We expend a majority of our emotional and working energy trying to sort through a few incredibly challenging problems but often don’t take the time to reflect upon “how we did” and whether we were simply seeking an “exceptionless rule”, i.e. seeking the alignment of others with our own values rather than trying to find a more middle-of-the-road moral ground that everyone can live with. In terms of expending our energy, doing so to understand just a little better the way we’re wired as well as the way we react to and process these kinds of difficult moral dilemmas makes good sense.

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This is the 2nd in a series of postings on the value of critical thinking in nursing ethics.

(Notice that a story has been in the news recently about how poorly most US college students do at acquiring critical thinking skills during their post-secondary years. See: Study: Students slog through college, but don’t gain much in terms of critical thinking skills.)

One of the absolutely fundamental skills of critical thinking is argument analysis, or the interpretation of argument structure. And the fundamental elements of argument structure are argument premises and conclusions.

In everyday language, the word “argument” refers to a heated debate. When people are “having an argument,” they’re disagreeing vigorously with each other. But the word “argument,” in the context of critical thinking, refers to a series of statements, in which some of those statements (called “premises”) are offereds as reasons to believe another of the statements (called the “conclusion.”)

Understanding the way an argument is put together — its structure — is a very good step towards understanding its strengths and weaknesses. Knowing, for example, that a given argument has 3 separate premises rather than just 1, is fundamental to looking for its weaknesses: the more premises it has, for example, the more possible points of criticism. But even more fundamental is the fact that we gain a better appreciation of someone’s point if we can get a better perspective on the shape of their argument.

Look, for example, at this argument:

Nurses go through a rigorous licensing process. And nurses proclaim their dedication to putting the good of their patients before their own good. So, nurses should be respected as professionals.

We can represent this argument graphically, by means of a diagram, as follows:

The arrows in this diagram represent the author’s intended logical “flow” — they can be read roughly as representing the word “so” or “therefore.” This argument has 2 premises, each of which gives at least some support to the conclusion. (The fact that there are 2 arrows indicates that there are 2 separate chains of logic here; each premise gives some reason to believe the conclusion.) At this stage all we are doing is sketching the shape of the argument; we are not yet engaging in a critique. But from a critical perspective, this means that if you find fault with one of the premises, the conclusion is still supported — at least to some extent — by the other.

Next, compare that one to this argument:

Nurses around here are unionized. No unionized group can really be a profession. So, nursing (here) isn’t a true profession.

That argument can be diagrammed as follows:

This argument also has 2 premises. But notice that (as implied by the line joining them, and the single arrow flowing from that line to the argument’s conclusion) these 2 premises are working together. They need each other in order to lend support to the argument’s conclusion. This means that a convincing criticism of either one of those premises robs the argument of all of its force. That’s not to say that the conclusion is false, even if its premises fail; it’s just to say that this argument can’t support the conclusion, if even one of its premises is in doubt.

Now, those are very very simple arguments, and the analysis suggested here is not exactly profound. But the simple process of sketching the shape of an argument — your own or someone else’s — is useful in making clear just how much support the argument has, or doesn’t have, and where its weaknesses may be.

The diagramming method used here is adapted from Lewis Vaughn and Chris MacDonald, The Power of Critical Thinking, 2nd Canadian Edition, Oxford University Press, 2010.

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