1. Angelucci, Patricia RN, CCRN, CNA, CHE, MS
  2. Carefoot, Shannon RN, CCRN, BSN

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Whether healthcare providers are treating patients in a critical care setting or in a home health environment, ethical dilemmas pose significant challenges to those providing care. Although we all have our own thoughts as to proper care protocols, it's important to maintain a respectful stance toward a patient's wishes-even if we might not agree. By having the appropriate information, the nurse manager can effectively assist staff members in addressing the varying degrees of moral anguish they might encounter.


Clashing principles

Consider the following example:


Mr. Smith is a patient in your critical care unit. He's hemorrhaging, and without intervention, he'll likely die. Based on his beliefs, Mr. Smith won't accept any blood products, even though he understands that such interventions could save his life. Mary, one of the nurses in the critical care unit, is visibly upset and struggling as she anticipates the outcome. Finally, Mary approaches the nurse manager and insists that the healthcare team intervene.


The intense moral anguish Mary is experiencing stems from internal conflict; her ethical framework clashes with the ethical beliefs of the patient. She doesn't agree with what's happening with Mr. Smith and feels badly, but can't articulate her position. It's obvious that Mary's operating from a personal ethical framework that revolves around several principles, the first of which involves fidelity to her profession.


The principle of fidelity infers keeping promises, honoring contracts and commitments, and truth-telling.1 By virtue of her role as a nurse, Mary has an implicit contract with the patient to provide him with the best care possible. She's also driven in her thoughts and actions by the closely intermingled principles of beneficence, benevolence, and nonmaleficence. Beneficence, in its simplest sense, means to "do good," and the partner of this is nonmaleficence, or "do no harm." Benevolence goes one step further than beneficence, in that it obligates us to act when we know an individual has a need.2


Mary believes strongly that by giving blood products, the healthcare team can "do good" for the patient and prevent more harm. Further, Mary feels that because it's evident that administering blood products can help save the patient's life, the healthcare team is obligated to do so.


Patient autonomy

When talking with Mary, the nurse manager should help her articulate and name her feelings as ethical principles. Also, the nurse manager points out that we must sometimes put aside personal convictions or the healthcare provider's perception that we know what's best for the patient. The patient has made clear his wishes, and his personal ethical framework is well known. Like Mary, the patient is driven by beneficence and nonmaleficence, but the patient's perspective varies dramatically. He believes that a blood transfusion will cause him harm, as well as grievous moral and spiritual distress.


Healthcare professionals must consider the principle of autonomy-the right to self-determination-which directs us to abide by the patient's wishes, unless the principle of justice comes into play. Mr. Smith has clearly articulated that he won't accept blood products and that he understands the dire consequences. As Mary develops an understanding of her feelings and a working knowledge of ethical principles, her view of the ethical world will expand. She'll eventually experience less moral anguish and greater acceptance of these types of situations.


Promote understanding

Clinical ethics is a practical discipline that provides a structured approach for identifying, analyzing, and resolving ethical issues in clinical practice. Exercising good clinical medicine and nursing practice requires a working knowledge about ethical issues and principles. Clinical ethics concerns both the ethical features present in every clinical encounter and the ethical problems that occasionally occur in those encounters. The principles rely on the conviction that even when perplexity runs high, nurses, physicians, patients, and families can work constructively to identify, analyze, and resolve many of the ethical problems that appear in clinical practice. Our actions or judgments about what should or shouldn't be done in particular situations are justified by moral rules grounded in ethical principles, which in turn flow from ethical theories.


Being involved in ethical dilemmas involving patients and their families can be a stressful process. These experiences can cause moral anguish and burnout, or a state of emotional and physical exhaustion. By understanding the drive underlying one's feelings, moral anguish-and the accompanying emotional and/or physical exhaustion-will be lessened when conflict occurs. Examining one's personal ethical framework promotes greater acceptance and understanding of another ethical framework when divergence exists. Nurse managers need to provide staff members with the tools to help them identify their individual personal ethical framework. The nurse manager should:


* listen mindfully as staff members discuss troubling moral dilemmas as they happen.


* clarify the aspect of care that's most troubling.


* facilitate informal debriefings with individual nurses and formal debriefings with staff as needed.


* research parallel ethical situations for background information.


* consult bioethics committees for issues that are appropriate.


* educate staff on ethical theories and principles.


* encourage staff to communicate directly in an open manner with other members of the healthcare team regarding ethical issues.



Know your framework

Nurse managers must seek ways to alleviate the anguish that can occur when healthcare providers are unaware or unclear of their own personal moral framework. It becomes a leadership imperative to assist staff toward greater ethical clarity, which may decrease episodes of moral anguish and reduce the resulting physical and emotional exhaustion. Perhaps then, Mary will face her next Mr. Smith with a whole new approach-one that's couched in knowledge, awareness, and acceptance.3




1. Mappes T, DeGrazia D. Biomedical Ethics. 4th ed. New York, NY: McGraw-Hill; 1996. [Context Link]


2. Frankena W. Ethics. 2nd ed. Englewood Cliffs: Prentice-Hall; 1973. [Context Link]


3. Angelucci P, Carefoot S. Working through moral anguish. Nurs Manage. 2007;38(9):10,12. [Context Link]