An ethical dilemma in school nursing.

School nurses must consider the ethical principles that guide everyday practice. Autonomy, beneficence, justice, and nonmaleficence are the ethical principles most often confronted in the school setting. When beneficent care-giving begins to conflict with the family's decision-making autonomy, paternalism, a form of beneficence, affects the family's autonomy. This creates an ethical dilemma for the school nurse who guides his or her practice by ethical principles but who also must decide when it is appropriate to refer a child or family to a medical provider for further evaluation. A case study is presented to illustrate a specific ethical dilemma. The ethical dilemma is described using a model that examines external factors, professional responsibilities, and possible courses of action. The discussion includes cultural considerations and barriers pertinent to the case example.     

Meals in nursing homes. An ethical appraisal

The ethical approach of artificial administration of food and fluids has been much enlivened in recent years. Nevertheless, the ethical implications of the day-to-day event of serving meals in nursing homes remain to be clarified. This paper has a double aim. First, I present a philosophical-ethical clarification of mealtime care in nursing homes. Second, I suggest several ethical orientations related to the nutritional problem among nursing home residents. I argue that caregivers must not only have considerable knowledge and skill in nutritional matters; it is only by integrating as much as possible an attitude of caring with the competent performance of care activities that 'good mealtime care' can be achieved.     

An autopsy of an ethical dilemma

An ethical dilemma was created for the intensive care unit staff following a physician's "No Code (Do Not Resuscitate)" telephone order. The author, the Director of Nursing involved, analyzes the short- and long-term outcomes of the situation. She applies a deontological framework, or duty-oriented ethical decision-making methodology, to help other administrators solve similar problems.     

Evolution of ethical debate about human gene therapy

Ethical issues generally evolve through four stages: threshold, open conflict, extended debate, and adaptation. The history of the ethical debate on human gene therapy is examined. The threshold was the Nirenberg appeal in 1967. The open conflict centered around two early controversial cases: those of Rogers and Cline. The extended debate has lasted from 1980 to the present, but now adaptation, i.e., a public policy, for somatic cell gene therapy is emerging.     

Informed consent and the elderly. An ethical challenge for critical care nursing

Nursing ethics was long reticent about ethical challenges that elderly patients pose for critical care nursing. One of these, the legal doctrine of informed consent, has important implications for critical care nursing ethics. Deriving from the principle of respect for persons and intended to preserve their autonomy, informed consent represents both a duty and an ideal for care givers to implement in the process of ethical decision making. All too often the ideal is lost, however, and the doctrine reduced to a sterile and bureaucratic procedure. When elderly patients are unable to give an adequately informed consent, advance directives can enable them to express their wishes by prior choosing. If they become cognitively impaired, however, it is much more difficult to determine what, if any, preferences such a patient might express if able to do so. Medical empowerment of the elderly, a laudable social goal, can be as contradictory as informed consent itself and many elderly patients may opt out of their own decision making. The resultant moral distress of such a complex process is still another ethical challenge that faces the critical care nurse. Because nursing holds a position of moral centrality among the health care professions, critical care nurses cannot avoid the prospect that issues like those identified in this article will continue to challenge and confront them in the coming decade. By turning to colleagues in nursing as well as other professions, nurses can best strengthen and consolidate their vital role as mediators of meaning and morality in life-and-death situations.     

Safety or autonomy. An ethical issue for clinical gerontological nurses

A common dilemma is whether to ensure a safe environment for the older person or to allow the older person to continue to live independently in an environment where personal safety may not be ensured. Conflicting opinions between marginally competent older adults and adult children regarding satisfactory living arrangements involve a forced choice between the moral principles of beneficence and autonomy. An ethical dilemma cannot be resolved on the basis of values alone. Pertinent ethical principles must be applied and an ethical theory used to guide the resolution. Autonomy is considered the supreme ethical principle in Western culture. The decision to set it aside, even to promote safety, takes rigorous ethical justification.     

On the scientific and ethical issues of fetal somatic gene therapy

Fetal somatic gene therapy is often seen as an ethically particularly controversial field of gene therapy. This review outlines the hypothesis and scientific background of in utero gene therapy and addresses some of the frequently raised questions and concerns in relation to this still experimental, potentially preventive gene therapy approach. We discuss here the choice of vectors, of animal models and routes of administration to the fetus. We address the relation of fetal gene therapy to abortion, to post-implantation selection and postnatal gene therapy and the concerns of inadvertent germ-line modification. Our views on the specific risks of prenatal gene therapy and on the particular prerequisites that have to be met before human application can be considered are presented.     

The ethical dimension in published animal research in critical care: the public face of science

Introduction

The ethical quality of animal research is important for many reasons, including for maintaining public support. We aimed to determine the reported attention to the ethical dimensions of the 3Rs (Refinement, Reduction, and Replacement) in critical care animal research published in 2012.

Methods

A data-collection form and instruction manual were created based on published recommendations, and completed for all consecutive critical care animal research (using mammals) publications from January to June 2012 in three critical care journals. Predefined subgroups were by journal, sepsis model, and animal age, compared by using the χ² statistic, with statistical significance accepted at P < 0.05.

Results

In total, 77 consecutive animal research publications were reviewed. Most studies did not report monitoring the level of anesthesia during invasive procedures, even when muscle paralytics were used, nor monitoring or treatment of expected pain. When euthanasia was used, the method was often not stated, and when stated, most methods were not appropriate for the species. A sample-size calculation was rarely used, and animal numbers were often poorly described. No studies performed a systematic review to ensure that the animal research would be useful and not simple repetition. Seventeen (22%) publications met the composite outcome of, if indicated, using anesthesia and pain control, and stating the method of euthanasia. Most studies were funded with public funds (foundation or government funding). Sepsis models less often met the composite outcome of, if indicated, using anesthesia and pain control, and stating the method of euthanasia (2 (7%) of 27 versus 15 (30%) of 50; P = 0.023). No other statistically significant differences were found in reporting of any criterion by animal age, sepsis model, or journal.

Conclusions

Reported (although not necessarily actual) ethical quality of animal research in three high-impact critical care journals during 6 months of 2012 was poor. This has important implications for the practice of critical care animal research.     

An approach to ethical judgments within the therapeutic alliance

In the high country of the mind one has to become adjusted to the thinner air of uncertainty, and to the enormous magnitude of questions asked, and to the answers proposed to these questions. The sweep goes on and on and on so obviously much further than the mind can grasp one hesitates even to go near for fear of getting lost in them and never finding one's way out. (Robert Pirsig, Zen and the Art of Motorcycle Maintcnance)     

High technology and nursing: ethical dilemmas nurses and physicians face on high-technology units in Norway

Results from two studies of ethical dilemmas nurses and doctors experience on two high-technology units are compared and discussed. The qualitative comparative methodology of grounded theory was used to generate theoretical frameworks grounded in the empirical realities of the units. The ethical dilemmas they faced were related to: treating the one vs. the common good; end of life questions; and resource allocations with inadequate staffing. Similarities were related to intensity and urgency of nursing care and patient treatment, clear nursing ideologies based on treating humans within a framework of hope, embracing technology and scarce resources. Differences between the two study units were patient diagnosis, hierarchical structure on one unit while one had a vertical structure and decision-making processes, and finally how nursing knowledge and autonomy were used. The two studies demonstrated that clinical, ethical and administrative interactions and decisions are highly compounded, stressful and intertwined.