Ethical Dilemmas in Nursing: Decision Making and Courage

Imagine having the responsibility to choose the “right course of action” in a situation that presents with many different “right actions”. Nurses are faced with this responsibility often; and most times it is not an easy decision process. This situation is known as an ethical dilemma (CNA, 2008). Ethical dilemmas arise in a situation when there are equally compelling reasons for and against two or more possible courses of action, and where choosing one course of action means that something else is relinquished or let go (CNA, 2008). The purpose of this paper is to use the Canadian Nurses Association Code of Ethics (2008), and consider how my own personal morals and values can help guide me through solving ethical dilemmas and also how I, as a future nurse can deal with the negative effects that may arise after an ethical decision is made. Strengthening your moral agency and moral courage as a nurse is also important in the ethical decision making process in order to successfully solve and continue to be able

to solve ethical dilemmas in the future.
Presentation of Ethical Dilemma
Sarah, a 15-year old, who at birth, experienced asphyxia, causing developmental delays, presents in the emergency department with severe abdominal pain. Her mother is with her and is very concerned about her health. The doctor has run tests and it turns out Sarah is pregnant. The nurse and doctor share this finding with Sarah without her mother in the room. Sarah extremely scared. When the nurse asks Sarah if she knows who the father is she tells the nurse that “her uncle made her do it”, and starts to cry. After discussing the situation, Sarah demands that the nurse not tell her mother and that she wants to get an abortion. She says she does not want anyone to know about this, and she doesn’t want to get her uncle doesn’t into trouble.
Nurses are often faced with situations where they need to go against the patient due to their incapacity to make their own decisions, where they must mandatory report, even if patient does not want to, or where their values and beliefs are not parallel with their patients. The above reasons are why I chose this ethical dilemma to solve, as it is very likely that I will be put into a real life situation including these ethical issues in the future.
Reflection of the 7 (Seven?) Primary Values.
As a nurse, I value the importance of implementing safe, compassionate, competent and ethical care. Unfortunately for Sarah, because of her developmental delay, she is unable to make her own decisions, so in order for myself to provide her with the safest, ethical care, I know that the right thing to do is share this information with her mother. Before I involve Sarah’s mother, and deal with the reported rape, I will implement responsibility A.3 from the Code of Ethics. I will build a trusting relationship with Sarah and I will educate her about the seriousness of this issue. By building a trusting relationship, I will be able to get through to Sarah the reasons why her mother is entitled to be informed and how her mother will be a beneficial support to her. Her mother will especially be support to the pregnancy, and the abortion decision. This will also allow for Sarah to see potential trusting relationships with other people such as councillors. In this case, I am using the ethical framework of act utilitarianism, by choosing the action of involving Sarah’s mother in her care, to maximize the overall good in the end.
Patient centered care is extremely important. Promoting the health and well-being of the patient allows for the highest possible level of health. For Sarah, I will promote health and well-being by involving her mother, and referring her for help and support. It is clear that she is scared, so these interventions will help her. I will apply responsibility B.3, by collaborating her mother and referring Sarah to a social worker and an abuse counselor. Collaboration of these three parties will help to maximize the benefits to Sarah. Her mother will be beneficial to her decision making, a social worker will be beneficial with providing pregnancy options and an abuse counselor can help Sarah to open up about the incident with her uncle. If I were to put myself in Sarah’s shoes, I would also be scared, but I know I would be happy to have support and help which is why I think collaboration with these parties will be of great benefit. This is supported by Carpers fundamental personal way of knowledge.
Nurses are to promote and respect informed decision making, however, in certain situations, it is a legal right for the nurse to go against this. Due to Sarah’s inability to be capable, I will follow the responsibility C.11 by involving her mother, as I know it is in Sarah’s best interest. With Sarah being developmentally delayed, her mother is her substitute decision maker, but still must respect the best interest of Sarah. I will work along-side her mother to help her consider the best interest for Sarah’s care regarding both the pregnancy and the rape. In Sarah’s case, abortion respectfully may be the best option, due to her developmental delay and incest. Conscientiousness is a framework that I will use, by acting with good intentions, and trying to do what is right and in Sarah’s best interest.
Nursing is a profession where it is important not to discriminate patients. In this case, I will preserve dignity by treating Sarah as an equal despite her developmental delay. Especially in Sarah’s case, because her mother is her decision maker, I will use responsibility D.1 by relating to her with respect. I will not look past Sarah and direct the attention and concerns strictly to her mother. I will respect that although Sarah is incapable of making her own decisions, it is still important to recognize and respect the her intrinsic. Another responsibility I think is necessary for successful decision making is D.8. In Sarah’s case, it is important to consider her emotional pain and suffering. I will implement and educate the patient on therapeutic techniques based on evidenced informed practice, that may be helpful in alleviating her emotional pain such as finding new hobbies and encouraging seeing a therapist. Conscientiousness is also shown here as I am acting with good intentions, trying to do what is right by still involving and respecting Sarah and also implementing therapeutic techniques.
Maintaining privacy and confidentiality is a very important value. It is important for nurses not to disclose any private patient information. To help guide me through solving Sarah’s ethical dilemma I will incorporate responsibility E.3. This responsibly sets out that nurses collect, use and disclose health information on a need-to-know basis. I will use this responsibility in my plan of action by firstly informing her mother about the situation and then I will report the rape to the police, seeing as it breaks section 151 of the criminal code: sexual interference (Branch, 2017). Although Sarah stated that she did not want to get her uncle in trouble it is mandatory for me to report this finding. The ethical framework used is legalistic considering it is the law to repot.
Promoting justice is also a value that can help guide me in dealing with this ethical dilemma appropriately. In Sarah’s situation, one may be very judgmental. A 15 year-old who is developmentally delayed, pregnant and a rape victim may be vulnerable to unfair care. While I am providing care to Sarah, I will use responsibility F.2, which values that nurses will refrain from judging behaviours towards persons receiving care. In order for myself as a nurse to provide the best care possible, I know that I must put my own personal opinions aside and focus on patient centered care. I believe that treating all patients with fair care follows under the focal virtue kindness.
Dealing with a situation like this could be extremely difficult. It is imperative that nurses recognize their competence limitations and seek additional information or knowledge when needed or even request a different work assignment. In Sarah’s situation, I was answerable to my practice. I carried out responsibility G.3 stating that I practiced within limits of my competence. I know that if I was unable to provide care to Sarah because of my personal values and beliefs, I would have to be accountable and request a different work assignment, however it would still be my duty to stay with Sarah until another nurse could take over. Being accountable allows one to be honest with thyself and with others, which is an important virtue ethic to have.
Moral Agency and Moral Courage
As a nurse it is important to follow moral agency.

Moral agency is defined as the capacity of a nurse to do what is good and right (CNA, 2008). Moral courage is also important and is described as standing up for what you believe in, even in the face of adversity (Burkhardt, Nathaniel, & Walton, 2014). I believe in this ethical dilemma I effectively carried out moral agency. Responsibility G.4 sets out that nurses must maintain fitness to practice, therefor in my current and future nursing placements I will continue to strengthen my moral agency with continued learning. I will continue my learning by attending seminars and taking additional courses to better my practice. Moral courage is also something that I will use in current and future placements, and I will strengthen my ability to be courageous by self-reflecting. I think journaling is an excellent method to help strengthen moral courage, as it will allow me to keep current with my own values and

beliefs.

Conclusion
Overall, the seven primary values set out in the CNA Code of Ethics (2008), allows for nurses to provide the greatest level of care to their patients. The values in the code provides nurses with excellent guidance while working through ethical dilemmas. Before writing this paper, I did understand the importance of the code and how it could be beneficial. This exercise has been a great benefit for my current and future nursing practice, allowing me to learn how to use the values and responsibilities when faced with ethical dilemmas.