prevalence of moral distress in nursing today?.
What are the incidence and prevalence of moral distress in nursing today?
Moral Choice and Ethical Dilemas
Read the following attached PDF titled:
• Moral choices in end of life care for children by Susan Stringer. Dated September 2013 | Volume 12 | Number 7
Writer, after you read the PDF File that I have attached by Susan Stringer please answer the following four (4) questions:
1. Describe the ways the subjects were vulnerable.
2. Is there any conflict of interest?
3. Which protections should be put in place to protect these subjects from harm?
4. What are the incidence and prevalence of moral distress in nursing today?
Stringer, S. (2013). Moral choices in end of life care for children. Cancer Nursing Practice, 12(7), 27-32 6p
CANCER NURSING PRACTICE September 2013 | Volume 12 | Number 7 27
Art & science | ethics
Moral choices in end of life care for children
Susan Stringer outlines different ethical stances and how they relate to the decision whether to discuss treatment with an 11-year-old patient
End of life care is fraught with difficulties and ethical dilemmas, which are even more problematic in the case of children (Royal College of Paediatrics and Child Health 2004). Although many of the issues encountered are often unavoidable, they can be emotive (Garrard 2009). Common issues include the management of pain and other distressing symptoms, uncertainties about the future, psychosocial, emotional and spiritual concerns, and providing compassionate support for children and their families. Parents may face heart-breaking dilemmas, such as whether to continue aggressive life-sustaining treatments, which may result in unbearable suffering; or allow their child to die. This article explores a case study of an 11-year-old boy with lymphoma to illustrate the ethical considerations of the decision-making process involved in his care. Three ethical issues – beneficence, autonomy and veracity – that are pertinent to the case study and that might need to be considered when providing end of life care
to children are discussed. The main elements of each of these ethical issues are examined and their implications for clinical practice are appraised. Healthcare workers should not only acknowledge the importance of good end of life care, but should also recognise the different types of ethical issues that may arise. To put these ethical debates into context, it is necessary to establish definitions of palliative care and ethics, and consider their fundamental philosophies and perceptions. Palliative care In 1986, the World Health organization (WHo) defined palliative care as: ‘The active total care of patients whose disease is not responsive to curative treatment.’ WHo stressed the importance of controlling pain and other symptoms, and psychological, social and spiritual problems, to achieve optimum quality of life for patients and their families. Ahmedzai et al (2004) expressed concern that this definition of palliative care could be construed as ‘relegating palliative care to the last stages of care’. The provision of palliative care is not restricted to those with incurable disease; consequently the original WHo definition has been revised (WHo 2002) to include problems associated with ‘life-threatening illness’, emphasising the need to introduce palliative care earlier on in the disease process. other tenets of palliative care specified by WHo (1986) include the intention to ‘neither hasten nor postpone death’, so that dying is seen as a normal process. A further document was produced to take into account the comprehensive needs of children (WHo 1998). The aim of palliative care is to reduce physical, psychological and spiritual suffering. This is
Susan Stringer is Macmillan head and neck nurse specialist, Sherwood Forest Hospitals NHS Trust, Mansfield, Nottinghamshire
Date of submission January 12 2013
Date of acceptance March 7 2013
Peer review This article has been subject to double-blind review and checked using antiplagiarism software
Author guidelines www.cancernursingpractice.co.uk
Abstract This article aims to demonstrate the extent to which end of life care for children raises moral dilemmas. It considers a case study of an 11-year-old boy with lymphoma, examining the considerations of the decision-making process involved in his treatment and drawing on various aspects of the scenario to illustrate and discuss different choices.
Keywords Autonomy, beneficence, children, end of life care, ethical issues, justice, non-maleficence, veracity
27-32 CNP Sept 2013.indd 27 03.09.2013 15:51
September 2013 | Volume 12 | Number 7 CANCER NURSING PRACTICE28
Art & science | ethics
endorsed by the department of Health’s (2008) End of Life Care Strategy, which recognises the many challenges faced in meeting the needs and preferences of people approaching death. difficulties are inevitably encountered in the provision of end of life care, with people’s views differing significantly, so a good understanding of ethical principles is imperative. Such principles provide a guide for healthcare professionals about their duty, responsibilities and conduct, and give a firm foundation on which to base their decision making. Ethics To contextualise the ethical themes raised by the case study (see panel below), it is necessary to explain what is meant by the term ‘ethics’. It has been described as ‘the study which arises from the human capacity to choose among values’, and is oriented to what is ‘right, fair, just or good; about what we ought to do’ (Preston 2007) or, more specifically, the ‘study of the process for determining the best course of action in the face of conflicting choices’ (Rushton 2001). The oxford dictionaries (2013) definition of ethics is ‘moral principles that govern a person’s behaviour or the conducting of an activity’ or ‘the branch of knowledge that deals with moral principles’. It is generally held that ethical deliberation necessitates sound moral reasoning to establish the best course of action (Rushton 2001, Preston 2007). However, disagreement about morality and moral views is commonplace and the literature describes several moral doctrines that are now explored.
Ethical relativism Ethical relativism observes that there are ‘no absolute truths in ethics, and
that what is morally right or wrong varies from person to person or from society to society’ (Encyclopaedia Britannica 2013a). This stance contends that ‘there is no such thing as what is “really” right’ (Encyclopaedia Britannica 2013a) and, in doing so, it rationalises the capriciousness of moral belief. Similarly, Garrard (2009) alludes to the view of individual moral views to be right for those who believe them, even if they may not be acceptable for others. This results in a situation where different moral views may be held, without any being essentially amiss. However, this moral perspective does have negative implications. Garrard (2009) explained that judging an action to be acceptable or unacceptable on the basis of customs or standards deemed right in that society leaves ‘no way of criticising people or societies who think that it’s right to harm children’, or who carry out other obviously ‘wrong’ deeds.
Consequentialism This postulates that actions should be judged right or wrong on the basis of their consequences (Encyclopaedia Britannica 2013b). In other words, it is ‘morally right to do whatever will produce the best outcomes’ (Garrard 2009). However, this theory has problems; not least the potential for disagreement about what constitutes ‘good consequences’. furthermore, it upholds the view that, provided we are ‘producing the best consequences, it doesn’t matter what kind of things we do’ (Garrard 2009). Perhaps the most eminent form of consequentialism, known as utilitarianism, supports the notion that the right course of action is one that maximises overall happiness or wellbeing to the greatest number of people (Garrard 2009). The question arises then for those who support
Case study Josh (not his real name) was an 11-year-old boy with lymphoma who relapsed after prolonged periods of hospitalisation as a consequence of his condition and the side effects from chemotherapy treatment. After an initial cycle of chemotherapy, Josh underwent further investigations, which confirmed that his cancer had returned. He went on to have further chemotherapy treatment, but was excluded from the decision-making process that led to this decision. The decision to give further treatment was made by Josh’s clinical team, with the consent of his
parents. The treatment was unsuccessful, but this fact was withheld from him until he had worked it out for himself. When he realised that he was in the palliative stage of his disease trajectory, Josh thought that he had been denied the opportunity to express his opinions and feelings about the situation. This secrecy initially induced feelings of confusion, anger and betrayal in Josh, and overshadowed his relationship with his medical team and his parents. However, subsequently, when they were all aware of the situation, it allowed them to talk openly.
27-32 CNP Sept 2013.indd 28 03.09.2013 15:51
CANCER NURSING PRACTICE September 2013 | Volume 12 | Number 7 29
the notion of consequentialism, and particularly utilitarianism, whether it is morally acceptable to treat a few people unfavourably, in pursuit of improving the lives of most people.
Deontology deontology asserts that certain things should be done ‘on principle or because they are inherently right’; thereby accentuating the concepts of ‘obligation, ought, duty and right and wrong’ (Encyclopaedia Britannica 2013c). The values of deontologists dictate that there are specific types of acts that we should do, and others that we should not do. for example, lying, stealing and killing the innocent are forbidden, while keeping promises and protecting the innocent are required (Garrard 2009). As with the other ethical theories, deontology also has its drawbacks, and a common criticism is that because there are several rules in this theory, conflicts between moral duties often ensue. Choosing between two moral duties may be difficult, and some situations demand infringement of one moral to uphold another. A further criticism is that, because deontology is based on absolutes and does not allow for grey areas, it compels people to uphold morals even when specific situations render this questionable. Absolute moral principles are often too general to deal with specific situations, and often result in ‘conflict of duty’. However, deontologists may overcome this by interpreting them differently – by ‘capturing
moral tendencies’ as opposed to thinking of them as absolute and exception-less; thereby ensuring that moral judgements are ‘sensitive to context’ (Garrard 2009). Four principle approach Principlism has been proposed as a form of deontology that considers the application of moral principles, as opposed to moral theory, to guide ethical decision making (Garrard 2009). A version of this, developed by Beauchamp and Childress (2009), proposed that there are four moral principles that ‘capture the core of ethical thinking in the domain of health care’ (Garrard 2009). This ‘four principle approach’ has become the foundation of medical ethics, and is now widely applied in decision making in health care. It assists doctors and other healthcare workers to make decisions on moral issues (Gillon 1994, Garrard 2009). The four principles are respect for autonomy, beneficence, non-maleficence and justice (Box 1). In addition to the four principles, two more values form the cornerstone of medical practice (Mohanti 2009): ¦¦ Veracity (honesty, truthfulness). ¦¦ Respect for persons (the right to dignity). The four principles approach is adaptable, and may be defensible by deontologists and consequentialists. However, one criticism of the approach is that it lacks any distinct method of prioritising between the principles in instances of conflict. Beauchamp and Childress (2009) accepted that ‘neither morality nor ethical theory has the resources to provide a single solution to every moral problem’ and that these principles should be used to guide decision making. Thus there remains a need for healthcare professionals to assess situations individually, before formulating an appropriate response. The case study (see panel, opposite page) serves to illustrate an ethical dilemma and highlights the stresses related to making difficult decisions.
Beneficence and non-maleficence Balancing beneficence and non-maleficence, or balancing benefit with harm, is evident in Josh’s case, although it is acknowledged that in many circumstances a ‘certain degree of harm may be necessary to provide a benefit’ (Thorns and Garrard 2011). Although Josh’s oncologist and his parents acknowledged that the second round of chemotherapy was aggressive and his chance of cure was minimal, Josh was not consulted before treatment, which went ahead without him being
Box 1 Four principles of medical ethics