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Nursing and the resolution of ethical dilemmas
Inherent to Nursing Care, ethical dimension includes having to decide about the dilemmas that arise in practice. Experience shows that generally we do not have a reference and then sufficient training to judge the ethical quality of our decisions and actions, reason why, in this article some methods are introduced that will facilitate this ethical analysis when faced with a conflict or dilemma that warrants it.
Key words: ethics; ethical analysis; nursing care.
Enfermería y la resolución de los dilemas éticos
La dimensión ética, inherente al Cuidado de Enfermería, incluye el tener que decidir sobre los dilemas que se presentan en su práctica. Generalmente, la experiencia muestra que no poseemos una referencia ni suficiente entrenamiento, para juzgar la calidad ética de nuestras decisiones y acciones, razón por la cual, en este artículo se muestran algunos métodos que facilitarán este análisis ético frente a un conflicto o dilema que así lo amerite.
Palabras clave: ética; análisis ético; atención de enfermería.
Enfermagem e a resolução dos dilemas éticos
A dimensão ética, inerente ao Cuidado de Enfermagem, inclui o ter que decidir sobre os dilemas que se apresentam em sua prática. A experiência mostra que geralmente não possuímos uma referência e depois suficiente treinamento, para julgar a qualidade ética de nossas decisões e ações, razão pela qual, neste artigo se mostram alguns métodos que facilitarão esta análise ética frente a um conflito ou dilema que assim o amerite.
Palavras chave: ética; análise ética; cuidados de enfermagem.
Nursing and the resolution of ethical dilemmas
1 RN, M.Sc. Professor, Universidad de Valparaíso, Chile.
Conflicts of interests: none.
Receipt date: September 9th 2011. Approval date: March 23rd 2012.
How to cite this article: Basso-Musso L. Nursing and the resolution of ethical dilemmas. Invest Educ Enferm. 2012;30(2): 260-268.
Essay • Ensayo • Ensaio
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We should begin by explaining what we mean when we say that our professional acts have an ethical dimension. In general terms, we could say that, while the technical dimension of our actions refers to work well done in terms of its effectiveness, the ethical dimension refers to the goodness and competence of the person who performs the job, i.e., individuals performing this action improve or perfect themselves as individuals by what they do. Thus, this dimension of ethics, inherent to Nursing Care includes having to decide on the dilemmas we face from an ethical perspective. There is no doubt that in Nursing practice we are continuously faced with ethical dilemmas, which sometimes we believe can be analyzed solely through common sense or intuition, but that after pondering over the facts, and the difficulty in finding the best path to its resolution, have shown that they require more than that, and in this search for a resolution, a consensus, a debate, and careful consideration must be employed, focused on complying with the ethical principles intrinsic to a profession whose purpose is the human being with his/her dignity. Experience shows that generally we do not have a reference and then sufficient training to judge the ethical quality of our actions in the nursing practice. This is not so obvious to us. For some, the ethical aspect is not a matter of analysis and will always be implicit in the development of a technique; for others, the scope of ethics belongs by definition to the realm of the subjective, hence, it should not even be necessary to ask ourselves about the existence of objective analysis criteria at this level. There are methods that allow for the development of reasoning and decision-making skills in situations of uncertainty, and that are used to solve these complex problems. The main objective of this article is to show some of the methods for the resolution of ethical dilemmas that have been considered more appropriate to the area of healthcare and that will help to facilitate the difficult task of analyzing these dilemmas ever present in the nursing practice.
Synthesis of content What are ethical dilemmas? They are problems or ethical issues without apparent solution, which must be resolved in the light of deliberation and analysis or negotiation of differences and ethical points of view to reach consensus on the solution. An ethical problem is distinguished from other problems when: the problem cannot be resolved in isolation by a review of scientific data or details of the situation; when there are two or more ethical values in conflict. The problem is confusing, common sense, logical, or intuition cannot be applied to make a decision; and the answer to the problem will be important and relevant to various human areas;1 analyzing why more than just common sense is needed, which has been defined as a common knowledge acquired by everybody through the spontaneous exercise of reason, but in a non-reflexive way. The certainties that make up what we call common sense are common to all, so that nobody lacks these, nor can they dispense with them when reasoning. These certainties are few, but absolute and universal. No man can speak and reason without using them as a starting point in his language, and as a logical structure of his reflection on reality, in search of wisdom of any kind. However, common sense is never found in its purest form.
It always relies on the existence of a thought and of a culture.2 It is also understood as a skill or the common sense that allows individuals to immediately access the principles, perceptions, expectations, practices, and beliefs common to their society. It is the most basic, primary, and immediate knowledge available to everyone as a member of a community, and this knowledge is also, an essential element to integrate into it. It must be taken into account that the elements of common sense are often not clear or explicit to all members of the community.3 When during human discourse statements compatible with common sense are expressed, these views are in principle acceptable but not enough for the resolution of
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an ethical dilemma because the latter cannot be generalized.
Considering all the complications resulting from this kind of exceptional dilemma, further, more elaborate information is necessary, along with a consensus of opinions that support its resolution. Another element that could be proposed to solve an ethical dilemma would be intuition. Intuition is the immediate or direct grasping of a reality, or the direct understanding of truth. Claiming to substantiate the ethical by intuition, stresses that although you can argue the existence of emotional insights that provide axiological knowledge, they do not serve as a basis, because in the case of discrepancies there is no criterion to determine what intuitions are correct.4 A basic intuition tells us that to morally assess an action it is not enough to describe the external (physical) act performed by a person. Thus, for example, if I invite someone to my home, an outside observer not could decide appropriately on the moral value of my action. This could correspond to an act of beneficence, to pay a wager, or to an instance to assault the guest. It is clear then that to determine the type of moral act corresponding to a physical act; we need additional information that goes beyond mere intuition.
The ethical dilemma appeals to rationality based on ethical principles, and outstrips intuitions as sources to resolve difficulties faced when making decisions and which lie precisely in the opposition between two ideas that may be good; it is not necessarily the opposition between good and evil. This means that to make the right decision, those involved have to think about the most correct because there are no incorrect decisions, and in that sense, people evaluate from the ethical principles, but also, from the results of the action that always considers the moral responsibility compared to the consequences of the acts. Complementing this, Aristotle already differentiated two levels of moral reasoning, one speculative in the form of universal mandates and truth: do good, avoid evil, live honestly; and another one, that attempts to judge as good or bad the particular situations for which there is no certainty and, therefore, no science and
which have a coefficient of uncertainty . There is only one way to resolve them: the discussion or effort to make wise and prudent decisions and which has discretion on the particular ethical situations in light of tolerance that is supported by consensus and the common discussion of moral problems.5 How could reflection start when there is an ethical dilemma? First, by making sure that you are actually faced with an ethical dilemma. Then, gathering all the relevant information on the case, considering the user’s perspective, family, institutional and social aspects. By reviewing and identifying the values themselves, in view of a situation in conflict; verbalizing the problem in a plural debate considering the principles of Ethics of the Discussion. Taking into account the possible courses of action; negotiating the result, which requires confidence in one´s individual point of view and respect for that of others, given that the bioethical consensus proposes a methodology to process moral conflict with the same attention to all points of view involved in its resolution. And finally, evaluating the decisions and actions accepted.
Some of the elements of the aforementioned ethics of discussion should be mentioned, its philosophical basis lies in the thesis according to which there is no sense, thought, truth, or value without language.6 This was then developed to substantiate Habermas “communicative action”, whose principles are: recognizing that no moral standard (value) may be excluded from debate, and determining the conditions in which the communicative interaction can take place. These include: its public nature; participation of as many speakers as possible in the debate; the non-limitation of the debate (depending on the necessity or urgency to reach an action and/or decision); equality and freedom of participants in the debate, where relations of authority, domination, or coercion will not have an influence; the principle of argument will govern, i.e., any claim is debatable and the argument that resists all objections is the best; the principle of consensus, where mutual understanding and argued and justified agreement is the purpose and normal termination of communicative interaction. An agreement thus obtained, justifies the decision
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and the action; and finally, the principle of reviewability; whereby, any agreement must be questionable if new arguments arise.7,8
Some proposed methods of analysis It is in the field of decisions from a bioethics perspective, where these dilemmas first appear, seeking to advance research and scientific development.9 Bioethics appeared during the early 1970s to defend and improve the living standards of human beings, and especially bound to identify problems of ethical dimension arising in healthcare, as well as the discussions and attitudes that tend to its clarification, management, or resolution.10,11 Various perspectives and suggested methods facilitate ethical analysis.
Since Beauchamp and Childress. Based on a prima facie analysis of the four principles that are somehow objective and inter-subjective primary duties, and which are morally obligatory, these principles are defined as propositions that establish duties and it is noted that a prima facie obligation indicates that it must be obeyed, unless in conflict on one particular occasion with an equal or stronger obligation. They are then not only prudential maxims, but proposals with a normative nature, which set out the conditions of permissibility, obligatory nature, correctness, or incorrectness of the actions affected or rejected, depending on the case, and, in addition, permanently open to review within their contents and formulations. They do not have a priority order nor can they be prioritized beforehand.12