OUTCOMES OF PATIENT EMPOWERMENT

Ethics & issuEs
In Contemporary

Fourth Edition

Margaret A. Burkhardt
PhD, FNP, AHN-BC

Alvita K. Nathaniel
PhD, FNP-BC, FAANP

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Ethics & Issues: In Contemporary ,
Fourth Edition
Margaret A. Burkhardt, Alvita K. Nathaniel

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iii

D e d i c a t i o n

To Joe and Tim

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iv

C o n t e n t s

Preface xvi

Acknowledgments xx

contributors xxi

Part i
Guides for Principled Behavior 1

chapter 1
Social, Philosophical, and Other historical
Forces Influencing the Development
of 2

Objectives 2
Introduction 3
The Influence of Social Need 5
Spiritual, Religious, Gender, and Philosophical Influences 8

Spiritual/Religious Influences 8
Ancient Times 9
The Early Christian Era 13
The Middle Ages 14
The Renaissance and the Reformation 20
The Modern Era 22

Summary 24
Chapter Highlights 25
Discussion Questions and Activities 26
References 26

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chapter 2
Ethical Theory 29

Objectives 29
Introduction 30

Ethics and 31
Philosophy 32
Morals and Ethics 35

Philosophical Basis for Ethical Theory 35
Theories of Ethics 38

Utilitarianism 40
Deontology 44
Virtue Ethics 48
Moral Particularism 51

Summary 53
Chapter Highlights 54
Discussion Questions and Activities 55
References 55

chapter 3
Ethical Principles 58

Objectives 58
Introduction 59

Respect for Persons 59
Respect for Autonomy 59

Recognizing Violations of Patient Autonomy 62
Informed Consent 64
Paternalism 65
Advocacy 67
Noncompliance 68

Beneficence 69
Nonmaleficence 71
Veracity 73

Confidentiality 76
Limits of Confidentiality 79

Justice 81
Fidelity 84
Summary 85

c o n t e n t s v

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Chapter Highlights 85
Discussion Questions and Activities 86
References 88

Part ii
Developing Principled Behavior 91

chapter 4
Values Clarification 92

Objectives 92
Introduction 93
What Are Values? 93

Moral Values 93
Acquiring Values 94
Self-Awareness 95

Enhancing Self-Awareness 96
Values in Professional Situations 98

Impact of Institutional Values 99
Clarifying Values with Patients 102

Summary 104
Chapter Highlights 105
Discussion Questions and Activities 105
References 106

chapter 5
Values Development 108

Objectives 108
Introduction 109
Transcultural Considerations in Values Development 109
Beliefs and Values 111
Theoretical Perspectives of Values Development 113

Piaget’s Stages of Cognitive Development 113
Kohlberg’s Theory of Moral Development 114
Gilligan’s Study of the Psychological Development of Women 115
Fowler’s Stages of Faith Development 116

Some Considerations 120
Summary 122
Chapter Highlights 123

vi c o n t e n t s

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c o n t e n t s vii

Discussion Questions and Activities 123
References 124

chapter 6
Ethics and Professional 126

Objectives 126
Introduction 127
Professional Status 128

Nurses as Professionals 130
Codes of Ethics 131

Themes of Ethics 134
Caring 134
Expertise 135
Autonomy 136

Accountability 139
Mechanisms of Accountability 139
Authority 143
Unity 144

Summary 145
Chapter Highlights 145
Discussion Questions and Activities 146
References 147

chapter 7
Ethical Decision Making 150

Objectives 150
Introduction 151
Problem Analysis 151

Moral Uncertainty 152
Moral/Ethical Dilemmas 152
Practical Dilemmas 154
Intervening Factors 154

Ethical Decision Making 158
Making Decisions 158

Ethical Decision-Making Model 163
Articulate the Problem 164
Gather Data and Identify Conflicting Moral Claims 165
Explore Strategies 166
Implement the Strategy 166
Evaluate Outcomes of Action 166

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viii c o n t e n t s

Moral Distress, Moral Outrage, and Moral Reckoning 170
Moral Distress 170
Moral Outrage 173
Moral Reckoning 174
Ways to Anticipate, Minimize, and Control Moral Reckoning 178

Summary 180
Chapter Highlights 181
Discussion Questions and Activities 181
References 182

Part iii
Principled Behavior
in the Professional Domain 187

chapter 8
Legal Issues 188

Objectives 188
Introduction 189
Relationship Between Ethics and the 189
General Legal Concepts 192

Sources of 193
Types of 194

Contemporary Legal Trends 213
Legal Trends Involving Managed Care Organizations 214
Malpractice Claims Against Nurses 215
Criminalization of Nurses’ Professional Negligence 216
Confidentiality of Electronic Communications 217

Risk Management 219
Maintaining Communication with Patients 220
Maintaining Conscientious Practice 221
Maintaining Autonomy and Empowerment 222
Liability Insurance 222

Nurses as Expert Witnesses 223
Summary 224
Chapter Highlights 225
Discussion Questions and Activities 226
References 227

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c o n t e n t s ix

chapter 9
Professional Relationship Issues 230

Objectives 230
Introduction 231
Problem Solving in the Professional Realm 231

Maintain Attentiveness to Personal Values 232
Clarify Obligation 232
Determine the Nature of the Problem 234
Choose from Alternative Solutions Thoughtfully 237

Nurses’ Relationships with Institutions 237
Nurses’ Relationships with Other Nurses 240
Nurses’ Relationships with Physicians 243
Nurses’ Relationships with Subordinates 246
Discrimination and Harassment 248

Racial Discrimination 248
Discrimination Against Persons with Disabilities 250

Sexual Harassment and Discrimination 251
Summary 253
Chapter Highlights 253
Discussion Questions and Activities 254
References 255

chapter 10
Practice Issues Related to Technology 258

Objectives 258
Introduction 259
Benefits and Challenges of Technology 259

Quality of Life 260
Principles of Beneficence and Nonmaleficence 261

Current Technology: Issues and Dilemmas 261
Treating Patients: When to Intervene and to What End 262
Issues of Life, Death, and Dying 262
Medical Futility 266
Do Not Resuscitate Orders 270
Artificial Sources of Nutrition and Hydration 273
Legal Issues Related to Technology 274

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x c o n t e n t s

Palliative Care 277
Palliative Care Conference 277
Examples of Potential Dilemmas with Other Technology 279
Controversial Technologies 281

Practice in the Midst of Technology 284
Technology, Privacy, and Confidentiality 284
Attitudes and Values 286
The Importance of Communication: Who Decides? 287
Caring: The Human Focus 288

Summary 289
Chapter Highlights 289
Discussion Questions and Activities 290
References 292

chapter 11
Practice Issues Related to Patient
Self-Determination 295

Objectives 295
Introduction 296
Autonomy and Paternalism 296

How Far Does Autonomy Go? 298
Informed Consent 299

Ethical and Legal Elements of Informed Consent 300
Role and Responsibilities: Informed Consent 301

Advance Directives 304
Decision-Making Capacity 306
Role and Responsibilities: Advance Directives 310

Choices Concerning Life and Health 312
Choices Regarding Recommended Treatment 313
Controversial Choices 316
Confidentiality 322

Summary 323
Chapter Highlights 323
Discussion Questions and Activities 325
References 326

chapter 12
Scholarship Issues 329

Objectives 329
Introduction 330

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c o n t e n t s xi

Academic Honesty 330
Research Issues and Ethics 332

Ethical Issues in Research 333
Special Considerations: Vulnerable Populations 339
More Than Protection of Human Rights 341
Ethical Treatment of Data 343

Summary 344
Chapter Highlights 345
Discussion Questions and Activities 345
References 347

Part iV
Global Issues That Interface
with Practice 349

chapter 13
Global Consciousness
in the Twenty-First Century 350

Objectives 350
Introduction 351
Earth Ethics and Health 351

The Earth Charter and 354
Disaster— Response and Ethical Considerations 356
Displaced Persons and Victims of Armed Conflict 358
War and Violence 360
Health Care Access and Financing 363
A Brief History of Health Care Delivery: The

Euro-American Experience 364
Early Eras of Health Care Delivery 365
Changes from the Middle Ages to the Industrial Revolution 366
Changes Influencing Development of Modern Health
Care in the United States 367

Global Needs and Finite Resources 375
Alternative Traditions of Health Care 379
Challenges for Rural and Urban Aggregates 381
Summary 382
Chapter Highlights 382
Discussion Questions and Activities 383
References 385

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xii c o n t e n t s

chapter 14
health Policy Issues 388

Objectives 388
Introduction 389
Political Issues 389
Health Policy 393

The Health Policy Process 395
Ethics in Policy Making 398
Research Data in Policy Making 399

, Policy, and Politics 399
Policy Goals for 401

Lobbying 402
Methods of Lobbying 402
Political Campaigns 404

Summary 405
Chapter Highlights 406
Discussion Questions and Activities 406
References 407

chapter 15
Economic Issues 409

Objectives 409
Introduction 410
Overview of Today’s Health Care Economics 410
Distributive Justice 412

Entitlement 413
Fair Distribution 416
Distribution of Resources 416
Theories of Justice 417

Recent Trends and Health Economic Issues 419
Health Care Reform 420
Managed Care 422

Summary 424
Chapter Highlights 424
Discussion Questions and Activities 425
References 426

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c o n t e n t s xiii

chapter 16
Social Issues 428

Objectives 428
Introduction 429
Social Issues 429

Poverty 429
Homelessness 431
Intimate Partner Violence 433
Human Trafficking 435
Increasing Elderly Population 436
Racism 437

Ethical Principles Applied to Social Issues 439
Justice 439
Nonmaleficence 439
Beneficence 440
Autonomy 440

Personal Impediments to Intervening with Vulnerable Groups 441
Victim Blaming 441
Language of Violence 441

Social Issues and Scholarship 442
Summary 443
Chapter Highlights 443
Discussion Questions And Activities 444
References 446

chapter 17
Gender Issues 449

Objectives 449
Introduction 450
Historical Perspectives and Overview of Gender-Based Issues 450
Gender Discrimination in 452

Women in 452
Men in 452
Gender Issues in Women’s Health 453
Gender and Caring 454

Sexual Harassment in 456

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xiv c o n t e n t s

Modern Sexism 457
Sexual Orientation 458

Caring for Lesbian, Gay, Bisexual, and Transgender Patients 459
Communication Issues Related to Gender 459

Nurse-Physician Communication 460
Communicating with Patients 461

Gender and Race 461
Summary 463
Chapter Highlights 463
Discussion Questions and Activities 464
References 465

chapter 18
Transcultural and Spiritual Issues 468

Objectives 468
Introduction 469
Transcultural Issues 469

Understanding Culture 469
Cultural Values and Beliefs 471
Culture and the Health Care System 475
Complementary Therapies 477
Legal Considerations Related to Transcultural Issues 479

Issues Related to Spirituality and Religion 480
Approaching Spirituality 480
Spirituality and Religion 482
Nurturing Spirit 486

Summary 488
Chapter Highlights 488
Discussion Questions and Activities 489
References 490

Part V
The Power to Make a Difference 493

chapter 19
Empowerment for Nurses 494

Objectives 494
Introduction 495

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c o n t e n t s xv

Influences on ’s Perceptions of Principled Practice 495
Influence of Mind-Set 495
Metaphors of 496
How Is Perceived by Others 498

Understanding Power and Empowerment 499
Personal Empowerment 501
Professional Empowerment 504

Unity in Diversity 506
Re-Visioning 508
Summary 510
Chapter Highlights 510
Discussion Questions and Activities 511
References 512

chapter 20
Facilitating Patient Empowerment 515

Objectives 515
Introduction 516
Patients and Empowerment 516
Nurses and Patient Empowerment 516

Attitudes of Nurses That Facilitate Empowerment 517
Knowledge and Skills Necessary for Facilitating Empowerment 517

Enhancing Patient Capacity for Decision Making 518
Barriers to Empowerment 519

Fostering Patient Empowerment 520
Summary 521
Chapter Highlights 522
Discussion Questions and Activities 522
References 523

Appendix A
Online Resources 524

Glossary 525

index 532

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xvi

P r e f a c e

We who lived in the concentration camps can remember the men who
walked through the huts comforting others, giving away their last piece
of bread. They may have been few in number, but they offer sufficient
proof that everything can be taken from a man but one thing: the last
of his freedoms—to choose one’s attitude in any given set of circumstances,
to choose one’s own way.

—V. E. Frankl,
Man’s Search for Meaning

As contemporary nurses, we face complex and challenging personal, in-
terpersonal, professional, institutional, and social issues. Appropriate re-
sponses to these issues are seldom clear. Ethical dilemmas, in particular,
involve choices with no clearly correct solutions. We believe that declaring
that there is one correct approach to solving ethical problems risks im-
posing personal values on others. We must be sensitive to that possibility
and recognize that our responses to dilemmas depend on such variables as
contextual factors, patient and family values, relationships, moral develop-
ment, religious beliefs, spiritual perspective, cultural orientation, and legal
constraints.

It is our intention in this book to (1) acknowledge that each person is a
moral agent, (2) raise awareness of the myriad factors that need to be con-
sidered when dealing with ethical decisions, (3) present a decision-making
model to help individuals learn to process information and move toward
action, and (4) affirm nursing as an ethically responsible profession. We
present ethical issues from the perspective of nursing, recognizing that re-
lationships and the authority to make decisions are affected by contextual
factors such as professional status; gender; the development of the profes-
sion; personal ethical stance; social, economic, institutional, and political
climate; and personal and professional empowerment.

Dealing with ethical issues requires skill in the processes of values
clarification, ethical decision making, self-awareness, empowerment,
transcultural sensitivity, and challenging injustice. The text poses questions

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P r e f a c e xvii

about contemporary issues and provides processes for the development of
sensitivity and skill in resolving ethical problems. Highlighting nurses in
a variety of settings and roles, the exercises and activities are intended to
facilitate self-reflection and awareness of personal approaches to issues and
decision making. Our goal is that you will become engaged in active learn-
ing throughout the text through the use of Case Presentations based on
real-life situations, Ask Yourself and Think About It exercises derived from
thought-provoking material and case presentations, and Discussion Ques-
tions and Activities.

Although acknowledging the rich and divergent history of nursing in
other cultures, we have chosen to write primarily from the Western per-
spective. The background that we give explains the many factors that lead
to social systems that either encourage or prohibit certain people from criti-
cally examining issues and making authoritative decisions. The book begins
with a chapter that explores the impact of historical factors, particularly
religion and gender, on the profession of nursing in Western culture. We
hope that this will help you to understand more fully the context of nurs-
ing and question arbitrary and artificial barriers to ethical decision making.

With a strong groundwork of ethical theories and principles in Part I,
subsequent chapters deal with various issues as they pertain to ethics and
ethical decision making. As you explore political, professional, legal, social,
and gender issues, we encourage you to look at the related ethical questions
and to continually move back and forth from the concrete to the abstract,
from the general to the specific, from the global to the personal, and from
issue to principle—recognizing the interrelatedness of many factors.

While continuing to discuss ethical issues from the perspective of nursing,
in this fourth edition we have included several new additions. We added more
in-depth discussions of the philosophical background of nursing and the devel-
opment of codes of nursing ethics and added content on ethics committee re-
ferrals, human trafficking, the Affordable Care Act, and spirituality assessment.
We also included new discussions of current controversial issues such as gen-
eral HIV screening and care of lesbian, gay, bisexual, and transgender patients.

Principled behavior in personal and professional situations is the organiz-
ing theme of this text. Beginning with a brief descriptive history of nursing as it
relates to ethics, Part I, Guides for Principled Behavior, presents ethical theories,
models, and principles that serve as guides for principled behavior. Part II, Devel-
oping Principled Behavior, discusses personal issues, including values clarifi-
cation, moral development, and ethical decision making. Part III, Principled
Behavior in the Professional Domain, presents professional and legal overviews
and chapters related to specific issues important to contemporary nursing. This
section includes discussions about autonomy, authority, accountability, codes
of practice, scholarship issues, practice issues related to health care providers,

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xviii P r e f a c e

systems within which nurses work, technology, and patient self-determination.
Part IV, Global Issues That Interface with Practice, addresses twenty-first-
century issues that require global consciousness as a background for under-
standing issues that nurses encounter in the contemporary health care system.
Considerations related to global health, political, economic, social, gender,
transcultural, and spirituality issues are discussed in light of nursing role,
potential dilemmas, and professional practice. Part V, The Power to Make a
Difference, focuses on developing skills to empower both nurses and patients
to make principled choices and act with courage.

Throughout this book, we have chosen to refer to the recipient of nurs-
ing care as patient rather than client. Since nurses function as members of
interdisciplinary health care teams and the term patient is commonly used
by other health providers, using a common language fosters better commu-
nication, understanding, and collegiality. In addition, the American Nurses
Association (2010) ’s Social Policy Statement notes that although
the term client is preferred by some nurses, it implies that the recipient of
care is able to choose one nurse from among many, a choice that typically
does not occur. We recognize that the terms client, person, or individual
may be the better choice in some circumstances and encourage the reader
to make that distinction if needed.

Although we have written from the Western perspective, we recognize
that our culture is a melding of traditions and people from many other
cultures. We have attempted to be sensitive in reflecting transcultural situ-
ations and issues. In that vein, you will notice that when referring to the
dates of historical events, we have used the designation b.c.e. (Before the
Common Era) rather than the more familiar b.c.

This book is meant to be very personal. We encourage you to become
engaged, examining and questioning your options and values as they relate
to real-life situations. As learning is demonstrated by changed behavior, we
hope that you will become a more sensitive, capable, courageous, and re-
sponsible decision maker and citizen. We believe with Phyllis Kritek (1994)
that “the measure of [one’s] character and worth is not whether [one has]
avoided making poor choices, but how willing [one is] to learn from these
errors in an effort to not repeat them, and how [one elects] to attend to their
consequences. . . . Finding meaning, discovering that which is of worth, be-
comes a searching process where everyone’s help is welcome” (pp. 21, 33).
This book is offered as a guide to help in the process of learning to make
sound choices and act in principled ways in both personal and professional
realms. As you use this book, we echo the same sentiment voiced by Flor-
ence Nightingale in the preface to her Notes on : “I do not pretend
to teach her how, I ask her to teach herself, and for this purpose I venture
to give her some hints” (1859, preface).

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P r e f a c e xix

References
American Nurses Association. (2010). ’s social policy statement:

The essence of the profession (New edition). Silver Springs, MD:
Author.

Kritek, P. B. (1994). Negotiating at an uneven table: A practical approach
to working with difference and diversity. San Francisco: Jossey-Bass.

Nightingale, F. (1859). Notes on nursing: What it is, and what it is not.
London: Harrison & Sons.

Additional Resources
The Instructor’s Companion Website is a complete teaching tool to aid
instructors in preparing lesson plans, lectures, and assessments. This re-
source is complimentary to all adopters of Ethics and Issues in Contem-
porary , Fourth Edition. The Instructor’s Companion Website
contains these instructional materials:

• Instructor’s manual that includes teaching tips and strategies.

• A computerized testbank with over 450 questions. You can use these
questions to create your own tests in seconds. And, you have the capa-
bility of adding your own questions and modifying existing ones.

• PowerPoint: More than 345 slides designed to help you with your class
presentations.

• ISBN: 978-1-1331-2917-2

CourseMate, accessed at www.Cengage.com/coursemate, helps the
student make the most of study time by offering access in one location to
everything needed to succeed. Ethics and Issues in Contemporary Nurs-
ing CourseMate includes an interactive ebook with highlighting and note-
taking ability and an interactive glossary. As an instructor, you can benefit
from the engagement tracker to monitor student progress.

To access CourseMate content:

Go to www.cengagebrain.com
For instant access code, ISBN: 978-1-133-12921-9
For print access code, ISBN: 978-1-133-12922-6

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xx

The journey of writing a book requires solitude and the companionship
and support of many people. We express gratitude to the many friends and
colleagues who have encouraged us along the way. Special thanks are due
to our mentors who have encouraged scholarship and principled behavior.
We are grateful to Mary Jo Butler, Sandra L. Cotton, Robin Shirley, and
Mary Gail Nagai-Jacobson for their contributions. Thanks go to all those
who gave the time and care to review the manuscript at various stages in
the writing process, providing us with helpful comments and guidance.

Finally, we are eternally grateful to our families, Joe Golden and Tim,
and Josh Nathaniel, and Maggie Belton, for their loving patience, humor,
caretaking, and encouragement throughout this challenging and growthful
journey.

A c k n o w l e d g m e n t s

Copyright 2013 Cengage …