1. What is Bioethics? …..and why is it important?

2. Week 1 Reading List • Shannon, T. (1997). (pgs.3-9 and 21-37). An Introduction to Bioethics. New York, NY: Paulist Press. • Lawrence, D. (2007).“The Four Principles of Biomedical Ethics: A Foundation for Current Bioethical Debate.” Journal of Chiropractic Humanities. 34-40. • Ulrich, C. M., Taylor, C., Soeken, K., O'Donnell, P., Farrar, A., Danis, M., & Grady, C. (2010). “Everyday ethics: ethical issues and stress in nursing practice.” Journal of advanced nursing, 66(11), 2510-2519.

3. Learning Objectives • Understand what bioethics is as a discipline, and how it manifests itself in our lives. • Develop a basic understanding of ethical theories and methods. • Develop an understanding of basic ethical principles prevalent in ethical discourse. • Understand the relationship between bioethics and nursing.

4. History of Bioethics Bioethics: Philosophical and interdisciplinary study of ethical issues brought about by advances in scientific and medical technologies. Common Bioethical Issues: • Deciding appropriate forms of care. (Medical futility, Withholding/ Withdrawing treatment, Experimental Treatment, Placement in a Facility etc.) • Determining patient preferences without clear instructions. (Advance Directives, Surrogate Decision-Making, Guardianship) • Deciding a patient/resident/subject’s best interest when there is disagreement. (Ethics Consults, Ethics Committees, Institutional Review Boards) • Creating and implementing policy related to ethical considerations for a variety of issues related to providing medical care and the impact of technological innovations on patient/clinician choices.

5. Origins of Bioethics Grew out of concerns regarding research ethics Nuremberg Trials (November 1945 – October 1946) • The Nuremburg Code (1947) • Voluntary Consent • Anticipate Scientific Benefits • Benefits > Risk • Animals Tested First • Avoid Suffering (No Intentional Harm or Death) • Subject Protected from Harm (Investigator Obligated to Stop if Harm Occurs) • Subject Free to Stop at Any Time Tuskegee Syphilis Study (1932-1972)

6. Origins Continued • The distinct academic field began in the 1960s in the United States. • Philosophers and theologians were later joined by physicians, ethicists, lawyers, and sociologists. • Scientific advances coupled with cultural changes • New emphasis on individual autonomy and rights (versus medical paternalism) • Focused on individual research participant (subject) and patients/residents (i.e. long term care facilities)

7. Ethical Theory What use is ethical theory? • Provides a common means/framework for approaching ethical problems Consequentialism Answers “What should I do?” by considering the consequence of action Advantage: Looks at the impact of decision and how it impacts people Disadvantage: No standard of measuring one outcome over another Examples of consequentialism: Utilitarianism Hedonism

8. Ethical Theory Continued Deontology Answers “What should I do” by specifying obligations or moral duties. Advantage: Provides clarity and certainty Disadvantage: Insensitivity to consequences (adherence to duty at all costs) Examples: Ten Commandments/Five Pillars/Five Precepts/Ten Tenets Jedi Code, Prime Directive

9. Ethical Theory Continued Rights Ethics Answers the question “What should I do?” by considering the rights or morals (positive or negative) involved. These are determined through an unwritten “social contract.” Advantage: Highlights the importance of the individuals morality in the ethical conflict. Disadvantage: Doesn’t help guide the resolution of conflicts (of rights), Examples: The Constitution/Bill of Rights guarantees (life, liberty, pursuit of happiness, fair trial, lawyer, freedom to practice religion (or not), free education, to marry, have children (or not)

10. Ethical Terms Tom Beauchamp and Benjamin Childress’ Four Principles of (Western) Bioethics (Principlism) Autonomy: The right of a person to have control over decisions regarding their care; also referred to as: respect for persons or respect for autonomy Requires: Ability to comprehend the information given Capacity to deliberate about plan Capacity to put the plan into action Manifested in healthcare primarily through the informed consent process, advanced directives and psychiatric advanced directives Related to the principle/concepts of Veracity: truth-telling Privacy: ability to choose which parts in this domain can be accessed by others, and to control the extent, manner and timing of the use of those parts we choose to disclose Confidentiality: the act of protecting certain information obtained through interactions between healthcare practitioners/researchers and patients/subjects

11. Elements of Informed Consent • Competence • Disclosure • Comprehension • Voluntariness

12. Ethical Terms Beneficence : medical practitioners have a moral duty to promote the course of action that they believe is in the best interests of the patient. • Requires: Assessment of the risks and benefits of an intervention. Choosing the intervention with the least risk and most benefit. Assessing if the option compatible with this patient’s individual circumstances and expectations for treatment Example: An 8 year-old child has been admitted to hospital with a significant open fracture to their left leg. The limb is deformed with significant bleeding and the patient is extremely distressed. The parents are demanding immediate action be taken. What are the options? What are the best or better option(s)?

13. Ethical Terms Nonmaleficense: The obligation to do no harm. Requires: The action/inaction is not intrinsically wrong. The intention of the action/inaction is good or for good effect. The good effect(s) outweigh(s) the bad . The good effect(s) is/aren’t a byproduct of a bad effect • Example: A 52-year-old man collapses in the street complaining of severe acute pain in his right abdomen. A surgeon happens to be passing and examines the man, suspecting that he is on the brink of rupturing his appendix. The surgeon decides the best course of action is to remove the appendix in situ, using his trusty pen-knife.

14. Non-Maleficence Continued From a beneficence perspective, a successful removal of the appendix in situ would certainly improve the patient’s life. But from a non-maleficence perspective, let’s examine the potential harms to the patient. • First of all, the environment is unlikely to be sterile (as is that manky pen-knife) and so the risk of infection is extremely high. • Second, the surgeon has no other clinical staff available or surgical equipment meaning that the chances of a successful operation are already lower than in normal circumstances. • Third, assuming that the surgeon has performed an appendectomy before, they have almost certainly never done it at the roadside – and so their experience is decontextualized and therefore not wholly appropriate. • Fourth, unless there isn’t a hospital around for miles this is an incredibly disproportionate intervention.

15. Ethical Terms Justice : Fair treatment of individuals in healthcare. Requires: Actions are equitable and fairly carried out from a societal perspective. It is compatible with the law and the rights of the individual. Ensures that no one is unfairly disadvantaged when it comes to access to healthcare. Example: Tara, a public health nurse in a rural community, has just learned that the local hospital is slated for closure. Losing the hospital would have dire consequences to a community that is already experiencing various health-related issues and social problems.

16. Ethical Terms Related to the principle of Nonmaleficence: Fidelity:  building and maintaining trusting relationships between clinicians/researchers and patients/subjects; keeping one’s promise. Requires: Treating all patients with respect (even the difficult ones). Adhering to established standards of care, ethical codes and relevant policies and laws. Maintaining confidentiality Example: An older patient with intact cognitive function is diagnosed with a terminal illness and he or she doesn't want to share that information with immediate family.

17. Bioethics in Nursing Practice Bioethics at the Bedside Maggie Little Kennedy institute of Ethics at Georgetown University March 2014

18. Bioethics and Nursing SPECIFICALLY: • Nursing ethics is a subfield of biomedical ethics that examines controversial issues in healthcare specifically from a nursing perspective. GENERALLY: • Nurses are bound by strict standards of professional conduct. • Nursing is a moral practice and is not practiced in isolation. • A basic understanding of ethics can help nurses to avoid actions that could result in morally significant harm to others. • Ethics also develops skills necessary to deal with morally significant circumstances in the workplace competently and effectively. • Ethics enable nurses to provide excellent clinical care resulting in personal satisfaction, patient satisfaction and organizational satisfaction.

19. The How of Bioethics Specifically in Clinical Care • Each clinician can practice excellent clinical care. Excellent clinical care includes consistently incorporating ethical understanding and the application of ethical knowledge into practice. • Through the proper use of clinical ethics consultations. • Through the incorporation of ethics committees into organizations where clinical care is provided.

20. The Value of Ethics Education in Nursing Practice Nursing is not merely a technical practice, but a fundamentally moral vocation. • The purpose of nursing is to carefor patients (to do good by them) therefore nurses need to understand what that means. • Ethical dilemmas, problems, conflicts, etc. arise all the time in the day-to-day practice of nursing. • Nurses need the tools of bioethics to navigate the ethical terrain of their profession.

21. Something to consider… Question: Doesn’t a nurse just need to follow the rules? Rules being institution policy and the law. Answer: Rules alone will never be specific enough to cover all the complexities of real life and the rules often give discretion to clinicians. • Therefore, you will need to know how to think through a situation and come up with an ethical course of action. • Also, having ethical reasoning skills will allow you to be a key participant and leader in your career. • Furthermore, the rules may not always be morally right.

22. Examples Example 1: Paternalism - it used to be policy not to let patients make their own medical decisions but to allow physicians alone to decide what was best for the patient. Example 2: Physician-assisted suicide - the act goes against the codes of ethics of the ANA and AMA and it is illegal in 45 states but that does not necessarily mean it is always morally wrong.

23. Ethics and Nursing Practice (Ulrich) Ethical issues create stress for nursing on a daily basis. • Protecting Patient’s Rights • Informed Consent • Advance Care Planning • Staffing Issues • Surrogate Decision-Making • End-of-Life Issues

24. Moral Distress Moral Distress: the emotional state that arises from a situation when a nurse feels that the ethically correct action to take is different from what he or she is tasked with doing. When policies or procedures prevent a nurse from doing what he or she thinks is right, that presents a moral dilemma. Moral distress can make nurses feel powerless, anxious, and even depressed.  Are Your Nurses Under Moral Distress?

25. Ultimately, a significant focus of bioethics today is that most medical decisions can be - and ought to be - made at the bedside and not in the courtroom. Understanding bioethics and ethical issues than can arise in nursing practice will help nurses navigate these issues and provide them with tools to help protect their patients’ rights.