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R E S E A R C H C O R N E R

Using ethical analysis when there

is no research n our last column, we dis- cussed approaches to solving clinical problems when there

is inadequate research to provide the basis for decision making. This column explores the con- cept of ethical analysis and how perioperative nurses can use this approach to answer certain clini- cal questions. Although ethical analysis may not be applicable in all situations, there are a number of clinical issues that are best addressed using this approach.

DEFINING ETHICAL ANALYSIS An ethical analysis is the sys-

tematic process of examining an issue using legal and moral val- ues and principles that govern conduct. Autonomy, nonmalefi- cence, beneficence, and justice serve as the four core concepts within biomedical models of moral or ethical reasoning. These concepts often provide the basis for decision making when research and scientific principles cannot answer difficult clinical questions.

Questions that often are best answered using an ethical analy- sis involve an individual’s or group’s rights or values. Examples of questions that emerge in perioperative nursing practice that may be answered by an ethical analysis include fl having observers in surgery

without patient permission, giving advice to patients about surgeons, participating in abortions,

fl reporting suspected drug use,

a not maintaining sterilization

a performing surgery on the standards, and

wrong patient or the wrong limb.

These issues are difficult and complex. Clinicians often attempt to resolve these issues by using their personal value systems or their emotions; however, with questions related to ethics, using these approaches puts the clini- cian at risk of imposing his or her beliefs on a patient or family member. What the clinician believes may not be appropriate or correct for the patient or fami- ly member.

In our society, there are few absolutely universal values. Perhaps the best example of a universal value is not breaking the law; however, throughout our history, individuals have broken laws in the name of improving society or establishing equal rights. The civil rights movement is an example of a time in US history when breaking the law led to significant changes in soci- ety. So, as it is with almost everything, nothing is absolute, making it difficult to create a value system that is appropriate for all individuals and situations.

FOUR PRINCIPLES OF ETHICAL OBLIGATION

The purpose of an ethical analysis is to use moral princi- ples to systematically analyze a specific question without impos- ing one’s personal value system on the issue. In an ethical analy-

sis, the patient’s values are of primary concern when compared to the health care provider’s val- ues. Some ethicists propose that an ethical analysis only can occur within the context of four guiding principles of ethical obligation proposed in biomed- ical models of ethical reasoning.

The first of these principles is respect for autonomy, which is defined as personal independence and freedom of choice when making decisions. Nonmalefi- cence (ie, the duty to do no harm) is the second guiding ethi- cal principle. Beneficence, the third principle, refers to doing good. The fourth principle is jus- tice, which also is known as fair- ness. The duty to tell the truth (ie, veracity), the duty to protect privacy (ie, confidentiality), and the duty to keep promises (ie, fidelity) are three secondary prin- ciples that are outlined by the American Nurses Association’s Code for Nurses.‘

Sarah Fry, RN, PhD, FAAN, proposes that advocacy, answer- ability, cooperation, and caring are four moral concepts that make up a framework for ethics in nursing practice? She describes three types of advoca- cy, including rights and protec- tions, values, and respect for individuals. Answerability reflects the nurse’s responsibility to the patient to promote health, prevent illness, restore health, and alleviate suffering. Co- operation is defined as working with the patient toward shared

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goals, keeping promises, and making mutual concerns a priori- ty. She further specifies caring as a natural state of caring, a moral ideal, and a precondition for car- ing for others. This nursing model may be appropriate for considering ethical dilemmas in nursing practice.

CONDUCTING AN ETHICAL ANALYSIS

nurses to conduct an ethical analysis in the context of these ethical principles or proposed frameworks. This process begins by first establishing the facts of the situation, creating a database of information, and including the perspectives of all interested par- ties. Before any situation can be considered fully, nurses need to collect as much information as is pertinent and available. The next step involves clarifying the Val- ues conflicts within the situation and understanding their signifi- cance. This may include identi- fying the specific rights within the analysis or the role of indi- viduals claiming rights. The third step in an ethical analysis is to construct and evaluate argu- ments.' During this phase, partic- ipants present and argue various positions. After this step, the dif- ferent positions are considered in relation to the guiding ethical framework. Next, nurses identify the outcomes of the various posi- tions and explore the possible outcomes. The final step involves building consensus for taking a specific course of action.

ple of how this might work in the OR would be to explore whether all patients are entitled to the same standard of care

It is possible for perioperative

Example in the OR. An exam-

regardless of the time of day. Perhaps you work in an OR where turnover time is the priori- ty and your supervisor tells you to flash sterilize equipment, including implants, for the sec- ond procedure of the day rather

An ethical framework helps

clinicians use moral reasoning

rather than values and emotions.

than process it using an auto- clave in the sterile processing department. You might question whether this is appropriate based on your knowledge of standards related to flash sterilization of surgical implants. Although there is limited research to support the recommendation not to flash sterilize implants, basic infection control principles have guided consensus statements by the Centers for Disease Control and Prevention when they make cer- tain recommendations.

Your supervisor has pushed you to keep things moving and not delay start times by simply flashing the tray of instruments and implants. In this situation, you might question the ethics of this practice and wonder whether this is in the best inter- est of the patient. This issue might be best addressed by an ethical analysis.

ested parties should be involved, In this instance, all the inter-

including surgeons, nurses, a clinical manager, an infection control professional, an anesthe- sia care provider, and any other individuals involved in the oper- ation of the OR and the surgical processing department. With this as a starting point, group mem- bers can begin to discuss the risks and benefits in compromis- ing standards to increase effi- ciency. A careful description of how flash sterilizing implants may affect both patient outcomes and efficiency are crucial to the discussion. In this situation, sci- entific principles and evidence- based protocols may be used as part of the baseline assessment.

Using an ethical framework can help the involved clinicians use moral reasoning, rather than personal values and emotions, to guide practice. The goal is to build consensus on a question in which those involved have con- flicting views and opinions.

USING AN ETHICS COMMITTEE

there are ethics committees charged with helping patients, family members, and health care providers take a systematic approach to ethical analysis. In most facilities, ethics committees consist of individuals with diverse backgrounds and per- spectives who have an interest and background in ethical rea- soning. Together, members of an ethics committee deliberate the various perspectives related to an ethics question, provide a frame- work for decision making, and summarize their findings. Ethics committees serve a critical role for answering complex questions (eg, terminating nasogastric feeding, using life-support inter- ventions). Ethics committees

In many health care facilities,

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also may address issues such as telling a patient his or her prog- nosis or telling family members a patient’s diagnosis. Most ethics committees welcome the chal- lenge of addressing issues or concerns that appear to have no right or wrong answer.

When you are unsure of what the right answer is, consider the efficacy of an ethical analysis.

Such an approach may help resolve issues and concerns that evoke controversy and divergent views. Identify resources and experts in your clinical setting who can help you with the process of exploring ethical con- cerns and questions. Certainly not all clinical questions can be solved with this approach, but there are many patient-related

concerns that cannot be answered any other way.

SUZANNE BEYEA RN, PHD, CS

AORN CODIRECTOR OF

PERIOPERATIVE RESEARCH

LESLIE NICOLL RN, MBA, PHD

AORN CODIRECTOR OF PERIOPERATIVE RESEARCH

NOTES 1 . American Nurses Association, Codefor Nurses

(Kansas City, Mo: American Nurses Association, 1985). 2. S T Fry, Ethics in Nursing Practice: A Guide to

Ethical Decision Making (Geneva: International Council of Nurses, 1994).

(New York: Oxford University Press, 1992). 3. M Benjamin, J Curtis, Ethics in Nursing, third ed

AORN Gains Community and National Exposure In a recent news story about a controversy involv- ing sales representatives in the OR, a reporter from a large metropolitan newspaper contacted AORN as an expert source of information on the subject. The article, which positioned AORN as a highly credible consultant, was picked up by the Knight Ridder news service, eventually reaching a circula- tion of 1 .S million people. That is just one of the many ways AORN is becoming regarded as the primary source of surgical care information-one of the Association’s strategic goals as we enter the next century. The following are other areas in which AORN is gaining publicity.

AORN has been asked to be a member of the national advisory board of Kaleidoscope, a cable television network, which will reach 15 million television households in 37 states. The network is designed to acquire, develop, market, and distribute health and disability- related programming. AORN is collaborating with several national nursing organizations (eg, Sigma Theta Tau, American Nurses Association) to create ways to increase the presence of nursing throughout the country. Preliminary plans include assembling a list of potential industry sponsors to develop commercials for national television and dis-

cussing a plan of action to contact hospital administrators, insurance executives, and policy makers about the role of nurses. AORN has responded to a request for nursing information for the television program “20/20.” The show’s producers are researching a poten- tial story, and we remain in communication with them. Twenty media members, including representa- tives from Healthcare Purchasing News, Today’s Surgical Nurse, and Materials Management in Healthcare, registered for this year’s Congress, looking to gain the latest news in the perioperative arena. In February, AORN Headquarters employees participated in Ground Hog Job Shadow Day, a national campaign that allows young people to “shadow” professionals throughout a day at work. By participating, AORN employees were able to let people in the community learn more about what perioperative nurses do. Also within the community, AORN worked in collaboration with the AORN of Denver chapter to offer information about perioperative nurses at the 9News Health Fair, a low-cost health clin- ic open to the public and spearheaded by a local television station.

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