Vol. 11 •Issue 6 • Page 83
Participative Ethical Decision Making
By Mary D. Calabro, NP, and Beatrice Tukoski, CNS
Nurse practitioners are often challenged by ethical dilemmas that appear to have opposing but equally valid solutions. The manner in which these dilemmas are resolved affects the therapeutic relationship between patient and provider. The ability to find solutions that recognize the opinions of all involved parties leads to more favorable results than an arbitrary or one-sided plan of care. In today’s time-constrained health care environment, a model to guide the resolution of ethical dilemmas is a valuable primary care practice tool.
This article presents a model for shared participative decision making using ethical concepts. This approach differs from current discussions about ethics, which often reflect the nurse in a secondary or dependent role. This model recognizes the leadership role of the nurse practitioner.
Introduction
Nurse practitioners care for diverse patient populations, many of whom may have multiple health problems. NPs are frequently faced with ethical dilemmas that must be resolved to foster therapeutic relationships. Dialogue and solutions must recognize the unique viewpoints of all parties involved, conserve time and resources, and ensure full participation by the patient. Often in the primary care setting, the primary care provider is the principle source of assistance and information. NPs provide leadership, accountability and sensitivity as they assist patients to fully participate in making decisions about their own health care.1
Current nursing resources for ethical decision making are primarily directed toward nurses in secondary and dependent roles; little is written specifically to guide NPs, who have a more autonomous scope of practice. In addition, the ethical dilemmas addressed in the health care literature are often associated with dramatic issues, such as end-of-life decision making. Ethical dilemmas in primary care are seldom so dramatic. They are, to a great degree, woven into the fabric of normative everyday health care. Often, in fact, the ethical dimensions of a situation are not recognized or are overridden by a paternalistic approach to patient care.2 Vigilance is required to recognize ethical conflicts before they become problematic. Knowledgeable preparation is necessary to find equitable and just solutions.
How can an NP resolve a conflict between a patient’s confidentiality and protective disclosure? Suppose a mother refuses immunizations for her baby, or demands to know her diabetic teen’s glucose level? What if an NP considers surgery necessary, but the patient disagrees and refuses?
A New Model
Calabro’s Participative Ethical Decision-Making (PEDM) Model offers tools for resolving such conflicts. The model, which Mary Calabro, NP, developed in 1997, provides a guide to address ethical dilemmas in an equitable manner.
A brief overview of ethical theory and principles provides background for how the PEDM Model developed.
Dilemmas, Theories and Principles
An ethical dilemma occurs when rival or opposing solutions to an ethical question occur — when both solutions are valid and grounded in two or more strongly supported ethical points of view. A decision or action that may be more desirable from one point of view is undesirable from the other and, if the alternate decision or action is chosen, the results will still only be desirable from one viewpoint.3,4
Solving an ethical dilemma requires rational analysis of the problem, thoughtful consideration of all valid approaches, patient participation and a decision that can be justified by ethical theory or grounded in a body of rules and principles (Table 1).
Ethical theories are systems of related concepts or principles used as frameworks, perspectives and supports for considering and solving ethical dilemmas. These theories differ according to where the philosophical emphasis for decision making is placed, i.e., a deontological (Kantian), utilitarian or contextual approach.
Deontological theories stress individual rights. An action is morally right or wrong according to a set of universal moral precepts that consider the person and his or her natural or bestowed rights of primary importance. This approach strongly supports consideration of individual rights, even when those rights may, for example, slow the implementation of universal public policy, restrict research, hinder application of new technologies, or result in an imbalance of the distribution of limited resources.
Utilitarian theories, on the other hand, emphasize the morality of an ethical decision, grounded in the concept of promoting the greatest good for the greatest number. A utilitarian approach is the basis for most public health policies that subsume individual choice to the provision of maximum benefits for the society at large. Examples are the requirement of childhood vaccinations regardless of personal opinions, or adding substances to public food or water supplies (fluoride, folic acid, etc) to provide maximum possible protection to the larger population.
Context-based ethics recognize the importance of the unique characteristics of a situation. Judgments about standards and ethics, which may be conflicting, are based on “best fit.” Bioethics must be applied according to the context of the situation.
No single philosophical approach is the absolute justification for every instance of ethical decision making. In fact, adhering to one or another of these approaches in a dogmatic or rigid manner can create additional conflict. Understanding the context in which an ethical dilemma arises and choosing an appropriate philosophical and moral justification is a complex process. Each dilemma requires assessment of the ethical principles involved in that situation.
Depending on the ethics resource, the specific list of ethical principles may differ slightly. But all have at least some of the principles identified in Table 1.5-11 The ranking and interpretation of the principles may differ according to a profession, an author, particular philosophy, cultural mores, religious convictions or life experiences.
Within what appears to be a confusing or bewildering array of approaches to ethical dilemmas, how can NPs be expected to have the wisdom and knowledge to solve an ethical dilemma? Consider these conflicts:
• the responsibility to inform an occupational injury patient about all options (veracity, autonomy) and the responsibility to an employer to be fiscally responsible (fidelity, justice)
• the assurance of patient confidentiality (fidelity, autonomy) and protective disclosure (nonmaleficence, fidelity)
• the best interests of the child and the decisions of the parent (autonomy, nonmaleficence), for instance, the parent who considers immunizations dangerous and the NP who views immunizations as protective (beneficence, justice)
• the husband whose diabetes is uncontrolled and the concerned wife who demands to know the husband’s status (autonomy, fidelity, nonmaleficence, veracity, justice)
• the NP who considers surgery absolutely necessary (beneficence) and the parent who refuses consent for surgery due to fear, misinformation or a belief that it is harmful (autonomy, nonmaleficence).
Most ethical dilemmas revolve around several principles and involve people with strong philosophical and moral reasoning that supports rival conclusions. Health professionals also have personal perceptions of professional standards that may dictate limits and imperatives of behavior. Resolution of these conflicts requires careful assessment and balancing of alternatives. This process is time-consuming and NPs seldom have enough time for long, lengthy searches for solutions.
The PEDM Model
Participative ethical decision making is a model for the systematic assessment and resolution of ethical dilemmas.12 It is a synthesis of concepts that are essential to health care professionals: ethics, communication, negotiation, autonomy and respect for people, professional standards and care that is culturally and contextually based. It is both practice- and theory-based.
The PEDM Model offers NPs a guide that will eliminate extra, random, consuming steps that may or may not lead to equitable solutions. The seven steps of PEDM are detailed in Tables 2 and 3.
Case Study
A 23-year-old mother brings her 3-year-old daughter to the primary care clinic for a sore throat. The child has a 6-month history of loud snoring with documented sleep apnea, persistent tonsilar enlargement and recurrent pharyngitis. The mother brought her child to an ENT surgeon 3 weeks ago as the result of a referral, but missed a previous appointment with the specialist. The surgeon scheduled a date for surgical removal of the child’s tonsils, but the mother did not bring the child for surgery. She also did not bring the child to a rescheduled clinic appointment. Now, the girl presents with another sore throat. The mother is adamantly against the surgery.
Applying the PEDM Model
Step 1: Is there a problem with no solution that is completely satisfactory to all parties?
Yes, the mother’s unwillingness to agree to surgery and the NP’s professional ethics, which require consideration of the surgical necessity and the possible impact of overruling the mother in an arbitrary or threatening manner.
Step 2: Who is involved, what is the issue or problem, and when does a decision need to be made?
Mother, child and possibly the community are involved. The conflict is essentially one of who has the right to make decisions for a minor child. Time is of the essence due to the child’s sleep apnea.
Step 3: What professional standards or codes of conduct are involved; what personal or professional principles and values are involved; where do these principles and values come from; which value, standard or principle is top priority; what are the other person’s roles or obligations?
The NP’s professional standards require provision of the safest care for all children. The NP brings a wealth of professional knowledge to the dilemma and knows that sleep apnea is dangerous (beneficence, maleificence). Advocacy is another principle to consider, especially in the care of a dependent minor. On the other hand, it is important to maintain a supportive, intact, caring family for the child. The NP may believe that the mother’s responsibility is to follow through with surgery as prescribed by the ENT.
Step 4: What are the patient’s principles and values related to the dilemma; where do these principles and values come from; what are her views of the problem’s significance; what are the mother’s views of the NP’s responsibilities and her own responsibilities; what is the most salient issue?
The mother confides that she is fearful of surgery because the child’s maternal grandmother advised her against surgery until the girl’s fifth birthday. The child’s mother relies on the advice and goodwill of her mother. Clearly, the mother and grandmother need more information, support and a chance to decide. The mother is obviously concerned about doing the “right” thing for her daughter. She did bring her back to the clinic (beneficence and fidelity) and she wants to protect her daughter from the danger of surgery (nonmaleficence), which she considers her responsibility. However, the mother disagrees with the solution (autonomy). The mother is adhering to her culture by relying on a maternal authority figure; her culture may also foster a distrust of health care providers.
Step 5: A mutual exchange of each other’s assessment, goals, desires, potential outcomes and feelings about the situation.
Fortunately, the grandmother and mother are able to meet with the NP, who provides information about the risks of surgery as well as the risk of apnea. She explains that the primary goal of all involved is to protect the child from harm. The mother and grandmother express their reservations based on a previous experience with surgery. Because of this exchange, the NP realizes that while all parties have the same goal, the perspective and fears of the mother and grandmother must be addressed.
Step 6: Is there an ethical framework that both parties could find acceptable: deontological, utilitarian or contextual?
Both parties are approaching the dilemma from a rights-based and a consequence-based framework: the right to a healthy life and prevention of post-surgical complications with consideration of the principles of beneficence, nonmaleficence and fidelity.
Step 7: Is there a possible solution that is acceptable to both?
Yes, the mother, grandmother and NP reach a conclusion that is acceptable to all — after the NP provides information about the safer anesthetics and monitoring available today, acknowledges the mother’s and grandmother’s concerns, provides support, and identifies a commonality of goals.
This was not a highly complicated ethical dilemma, but it was essential to the health of the child and family to seek an acceptable resolution. Using Calabro’s Participative Ethical Decision-Making Model to find an acceptable solution saved time, strengthened a trusting and caring relationship, and provided the dependent child with the needed intervention.
The consequences of not recognizing all the parameters of this dilemma could have had any number of dire results. For instance, sensing neglect of her concerns, the mother could have left with the child and never returned. Or, the NP could have coerced the mother into agreement and thereafter estranged the mother because threats and coercion had broken the bond of trust. Or, the relationship and trust between mother and grandmother could have been damaged if the mother were forced to accede to medical directives without involving the grandmother in the decision-making process.
Trust is Essential
Nurse practitioners are in a unique position in the health care arena because they focus on building trusting relationships with patients. Current literature about ethical dilemmas too often casts the nurse in a secondary or dependent role and is not specific to NP scope of practice.
Calabro’s Participative Ethical Decision-Making Model offers all NPs a model for the systematic assessment and resolution of ethical dilemmas that is applicable to their unique role. We have used the model to reach common ground on immunization, discipline and compliance. The PEDM Model incorporates concepts essential to primary care, such as communication, negotiation, autonomy and respect for people, rights, professional standards, ethical principles, and culturally and context-based care.
Applying the PEDM Model will increase proficiency in ethical decision making, whether the conflict is between patient and professional, between peers or between NPs and their administrations. The model has the potential to reduce the time spent searching for possible solutions in an unsystematic way, reduce conflict and build trust between people who hold valid but opposing ethical viewpoints.
References
1. Leininger M. Transcultural Nursing: Concepts, Theories, and Practices. New York: John Wiley & Sons; 1978.
2. Barry MJ. Involving patients in medical decisions. JAMA. 1999;282:2356.
3. Beauchamp T, Childress J. Principles of Biomedical Ethics. 4th ed. New York: Oxford University Press; 1994:396-418.
4. Davis A, Aroskar M, Liaschenko J, et al. Ethical Dilemmas and Nursing Practice. 4th ed. Norwalk, Conn.: Appleton & Lange; 1997.
5. American Medical Association. Principles of Medical Ethics, 2001. Available online at: http://www.ama-assn.org/ama/pub/category/4256.html.
6. American Nurses Association. Code for Nurses, 1980. Available online at: http://nursingworld.org/readroom/position/ethics/etcode.htm.
7. American Nurses Association. Scope and Standards of Advanced Practice Registered Nurses. Washington, D.C.: ANA; 1996.
8. American Nurses Association. Ethical Principles, 2001. Available online at: http://www.nursingworld.org/ethics/ecode.htm.
9. Fry S. Ethics in Nursing Practice. Geneva, Switzerland: International Council of Nurses; 1994.
10. Husted G, Husted J. Ethical Decision Making in Nursing. St Louis: Mosby; 1995.
11. Pelligrino E, Thomasa D. The Virtues in Medical Practice. New York: Oxford University Press; 1993.
12. Calabro M. Ethical decision making in primary care. Unpublished Manuscript, 1997.
Mary Calabro is a pediatric nurse practitioner with a master’s degree who is a lecturer and lead NP faculty member at Kent State University in Kent, Ohio. Beatrice Tukoski is a clinical nurse specialist with a doctorate degree in bioethics who is a professor in the adult NP program at Kent State University.
Table 1: Basic Bioethics Principles
Beneficence — doing good, benefitting positively, caring
Nonmaleficence — doing no harm, causing no injury
Justice — equitable distribution of benefits or consequences
Veracity — maintaining truth, never lying
Autonomy — respect for individual human dignity, rights and culture
Fidelity — maintaining trust, confidentiality and integrity
Table 2: Calabro’s Participative Ethical Decision-Making Model12
Step 1: Identify the Ethical Dilemma.
Is there a problem with no solution that is completely satisfactory to all parties?
Step 2: Delineate the Variables of the Dilemma.
Who is involved, what is the issue or problem, who else has influence, and when does a decision have to be made?
Step 3: Assess the NP’s Perspective on the Ethical Dilemma.
What professional standards, codes of conduct or legal obligations are involved?
What personal or professional principles and values are involved?
Where do these principles and values come from; which value, standard or obligation?
What is the NP’s view of NP and patient responsibilities?
Examine own values and morals to understand those of the other person.
Step 4: Assess the Patient’s Perspective on the Ethical Dilemma.
Use communication skills such as active listening, reflection, clarifying, summarization and validation to convey
acceptance of the other person’s perspective.
What are the patient’s principles and values related to the dilemma? What are the origins and influences (consider ethnic,
cultural, familial, experiential influences)?
What are the patient’s views of the problem’s significance and related issues?
What knowledge does the patient need?
What are the patient’s views of the NP’s responsibilities and his or her own responsibilities?
What is the patient’s salient issue?
Who is in the patient’s sphere of influence? (This is crucial for any solution to be relevant and satisfactory.)
Step 5: Share Assessment and Goals in a Participative Way.
Is there a mutual, open exchange and regard for each other’s assessment of the dilemma, expectations and goals, desires and needs, potential outcomes and feelings about the situation? (This can be threatening to some people.)
Step 6: Identify an Acceptable Ethical Framework for Working on the Issue.
Is there a mutually tenable, acceptable ethical framework: deontological (rights-based), utilitarian (consequential) or contextual (case-based)?
Step 7: Identify an Acceptable Solution.
Is there a possible solution that is grounded in freedom of choice and ethical principles and is acceptable to both parties? Consider all solutions proposed by either party. Any information the NP uses to support a solution must be reliable.
Table 3: PEDM: Short Form
Step 1: Identify the ethical dilemma.
Step 2: Delineate the variables in the dilemma.
Step 3: Assess the NP’s perspective of the ethical dilemma.
Step 4: Assess the patient’s perspective of the ethical dilemma.
Step 5: Share assessment and goals in a participative way.
Step 6: Identify an acceptable ethical framework for resolving the issue.
Step 7: Identify an acceptable solution.
