Running head: MORAL MODEL 1

Ethical Decision Making in the Operating Room

Mary-Margaret Whitten
Old Dominion University
Running head: MORAL MODEL 2

Ethical Decision Making in the Operating Room

“Morality plays a distinctive role in the lives of human beings (Killen, 2002),” by

providing principles for social organization. This includes direction on how to “control the use of

specialized and skills that are important in highly valued aspects of human life” (Killen, 2002).

Professions are one example of these social structures developed to control those special skills

and knowledge. Professions set the norms that define professional practices, however, “the

norms of the profession are not the ultimate determinants of right and wrong (Killen, 2002).”

Ethical issues arise in the daily clinical situations registered nurses (RN) encounter in the

operating room (OR). Because my patients are under anesthesia the important ethical issue of

autonomy is violated because the patient is unconscious and unable to speak for him or herself. I,

as a nurse must advocated for my patients when they cannot.

I work with three gynecologists from a nearby practice who operate at my facility

occupying three rooms while performing anywhere from 8 to 12 robotic hysterectomies in 8 to

10 hours. The group would move from room to room like an assembly line performing surgeries

on the patients in no particular order, operating together, and sometimes leaving the facility to go

deliver babies at other hospitals. While all three doctor’s names were on the consent, I often

heard the surgeons telling their patients that he would be with them the whole time during their

surgery. This is untrue. Sometimes two of the doctors would perform and finish the third

doctor’s surgeries before the third doctor even arrived at the facility. When patients ask me “is he

a good surgeon?” I am often torn about what to say.

This paper will evaluate the moral dilemma that results when ethic principle of truth-

telling and beneficence are in conflict when a surgeon is mechanically competent but has

unethical practices. I will use the MORAL model to evaluate the current dilemma while
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weighing all the options and choosing the best possible outcome for the greatest number of

people while causing the least amount of harm.

Dilemma

The dilemma related to this questioning of the surgeon’s competence is that there are

multiple ways I could respond to the patient’s request, and it is difficult, sometimes impossible,

to determine the “best” choice of answer for the patient’s needs. According Provision 3, of the

American Nurses Association (ANA) Code of Ethics for Nursing, “the nurse promotes,

advocates for, and protects the rights, health and safety of the patient” (ANA, 2015).

Additionally, “in the context of a patient-nurse relationship, the nurse’s legal duty is to ensure

that the treatment provided complies with the standard of care” (Mathes & Reifsnyder, 2014).

I know the two responses I would give to the patients in this situation are simple and

straightforward. I can tell them how I honestly feel, my truthful feelings about the gynecologist

group or I can smile, nod my head and agree as I roll them back to the OR suite. The reason its

an ethical dilemma is because there is no right answer. Culturally a nurse is not supposed to talk

poorly of the surgeons. What happens in the OR stays in the OR. When asked questions nurses

should “sugar coat” the information to uphold the allusion that the surgeons are in charge and we

are his employees. By speaking up I may cause patients to cancel surgeries and therefore lose

money for both the hospital and the surgeon. I may lob if my employers find out. Alternatel, if I

do not speak up I will uphold the lie that the surgeons are operating on the patients they say they

are, and are involved from start to finish, never leaving the patient’s side as they claim. I may

even be putting my own license on the line by allowing this to happen without speaking up.

Furthermore, I do believe the surgeons are competent in the surgeries they perform. They are not
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my first choice but that is information not shared with a patient because my opinions are not

facts.

I know that from the hospital and surgeon’s perspective I have no right to speak my

opinions to patients. I know they would not want their patients to know they were not in the

room for the entire surgery as they claimed. I know the surgeons could risk losing their license or

facing malpractice or negligence charges. The hospital could lose accreditation or magnet status.

The OR metrics would be skewed in this situation because I would be spending more time

talking with patients causing delays in cases and wasting OR time. In the operating room time is

money and an OR minute is worth much more than any minute of my work. Additionally,

stockholders in the hospital do not want these types of discussions taking place because it

decreases revenue and puts less money in their pocket. No one likes to wait in the OR. They

would rather us take a patient back and get started on time than make sure we are doing what is

in the best interest of the patient. As RNs, we must advocate for our patients because they can’t

and don’t understand how our system works or how to make sure they are best looked out for.

Unfortunately, the nurses who are taking care of these patients in the OR have the least amount

of autonomy to pursue these patient needs. They barely have time to go to the bathroom much

less to make sure a patient’s consent is true and based on valid expectations.

MORAL Model

There are two options I have chosen to explore using the MORAL model. The first option

is my current practice. I tell the patient the surgeon is a competent or skilled choice. The second

practice I have never tried. The truth. What I truly think about the surgeon’s competence has

never left my lips.

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The benefit of telling the truth, that you don’t think the surgeon is ethical in his practice,

is that you didn’t lie. Lying is unethical and immoral in most situations. The patient will also

know the truth and have all the tools he or she needs to truly give “informed consent.” The

patient may cancel the surgery and find someone more suitable to do their surgery. The negatives

are that the patient may have the surgery anyways and go to sleep panicking. They may not heal

as quickly due to stress. They may imagine a problem that is never actually there. The harm from

this type of veracity would include defamation of the surgeon. Without hard facts my opinion is

not a valid source of information. The problem with this truth is that it is that the group of

surgeons are basically competent and they have comparable outcomes to other surgeons. For this

The doctor would not like for the nurse to divulge how things work behind the OR doors because

it would open them up to law and malpractice suits by almost any patient the surgeons had

operated on in the past. It would bankrupt the group. The doctors think it is ok because no one is

getting hurt, and the surgeries are getting done efficiently and properly. This could also hurt the

hospital system because it owns the gynecological practice. Once word got out they could have a

civil action lawsuit brought against them. The financial ramifications of my telling the truth are

huge, which honestly makes the dilemma all the more daunting.

I know the truth might save future women from suffering. The societal / professional

norms are that the doctor, the one you researched for weeks, and gathered all the information on

the one you chose to performed your procedure, is the surgeon who is cutting you open and

performing your surgery in its entirety. Telling the truth may elicit changes related to the surgical

norms as a whole. It may make governing agencies come down harder on hospitals that are

“bending the rules” to get cases finished in a quick time frame.

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Unfortunately, medicine is now about money. They want perioperative nurses to move

faster, take on more cases, and keep them moving. This means no matter what you get this

patient into the operating room on time. The benefit to me keeping the surgeon’s unethical

practices to myself is that I get to keep my job. I get to continue to work for the hospital and the

surgeons are making more money so they stay happy and continue bring in more patients and

make even more money for the hospital system so the hospital system is happy. In terms of doing

the most good for the most people this seems like the obvious choice. However, this option does

not represent the patient as a stakeholder in the equation. Patients deserve the respect to make

choices based on actual results. Whether or not the surgery outcome is favorable is irrelevant to

the patient that feels their autonomy has been stripped away.

Plan

Given these two opposite approaches it is clear that both are valuable for different

reasons. If one is approaching the situation from a utilitarian perspective the choice is easy.

Continue the practice as is and don’t tell the patients what is really going on. However, I believe

that veracity is more important here. People should not be lied to about their medical procedures.

History proves that people do not like to be lied to about their health. I believe there is a way that

both could happen. A combined multifaceted approach towards the dilemma could eliminate the

situation all together. If the doctor would spend a bit more time with the patients while

consenting them for surgery explaining how he and his surgeons practice and have the patient

agree to the situation. This would not cost anything and gives the patients the option to say no. It

shouldn’t even hold up the surgery schedule because if someone does not consent the case could

be moved to the end of the day and keep the other rooms moving forward. This small change

could make the situation and ethically sound one based on the principles of beneficence,
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autonomy and justice. The doctors will effectively do the most good, creating the least amount of

harm, while respecting the rights and dignity of the stakeholders and promoting the common

good. I propose to call a meeting including the OR director, the physician group and some of the

concerned nurses to deliver this message.

Conclusion

While there is never a situation that works out perfectly I believe there is very little to

give up and so much to gain for all the stake holders in the situation. I wish I had explored this

issue earlier because as a nurse, I need to make sure that the principles and ethics that are

morally significant are upheld as the profession moves into the future. I have been blindly

maintaining the status quo when I could have easily already dealt with this issue. I look forward

to using this paper to speak with my director about changes we can and will make regarding this

physician group in the future.

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Reference

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Killen, A. R. (2002). Stories from the Operating Room: Moral Dilemmas for Nurses. Nursing

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