Ethical Issues and professional Advocacy Ethics is the systematic study of what a persons conduct and actions ought

to be with regard to himself or herself, other human beings; and the environment. It is the justification of what is right or good and the study of what a persons life and relationships ought to be, not necessarily what they are. Applied ethics requires application of normative ethical theory to everyday problems. The normative ethical theory for each profession arises from the purpose of the profession, the values and norms of the nursing profession therefore provide the foundation and filter from which ethical decisions are made. The nurse manager, however, has a different ethical responsibility than the clinical nurse and does not have as clearly defined a foundation to use as a base for ethical reasoning. Because management is a discipline and not a profession, it does not have a defined purpose, such as medicine or the law, therefore, it lacks a specific set of norms to guide ethical decision making. Instead, the organization reflects norms and values to the manager, and the personal values of manager s are reflected through the organization. The managers ethical obligation is tied to the organizations purpose, and the purpose of the organization is linked to the function it fills in the society and the constraints society places on it. Therefore, the responsibilities of the nurse manager emerge from a complex set of interactions. Society helps define the purposes of various institutions, and the purposes, in turn, help ensure that the institution fulfills specific functions; however, the specific values and norms in any particular institution determine the focus of its resources and shape its organizational life. The values of people within institutions influence actual management practice. In reviewing this set of complex interactions, it becomes evident that arriving at appropriate ethical management decisions is a difficult task. Not only in nursing management ethics distinct from the ethics of clinical nursing, but it also distinct from other areas of management. Although there are many similar areas of responsibility between nurse managers and non-nurse managers, many leadership roles and management functions are specific to nursing. These differences require the nurse manager to deal with unique obligations and ethical dilemmas that are not encountered in non-nursing management. In addition, because personal, organizational, subordinate and consumer responsibilities differ, there is great potential for managers to experience intrapersonal conflict. Multiple advocacy roles and accountability to the profession further increase the likelihood that managers will be faced with ethical dilemmas in their practice.

To make ethical decisions, the manager must use a professional approach that eliminates trial and error and focuses on proven decision making models or problem solving processes. Using a systematic approach allows managers to make better decisions and increase the probability that they will feel good about the decisions they have made. Systematic approaches include ethical frameworks and principles and theoretical problem solving and decision making models. ETHICAL DILEMMAS Individual values, beliefs and personal philosophy play a major role in the moral or ethical decision making that is part of the daily routine of all managers. How do managers decide what is right and what is wrong? What does the manager do if no right or wrong answer exists? What if all solutions generated seem wrong? Ethical dilemmas can be defined as situations in which one must choose between two or more undesirable alternatives. Curtin (1982) maintains that for a problem to be an ethical dilemma, it must have three characteristics. First, the problem cannot be solved using only empirical data. Second, the problem must be so perplexing that deciding what facts and data need to be used in making the decision is difficult. Third, the results of the problem must affect more than the immediate situation; there should be far reaching effects. The way managers approach and solve ethical dilemmas is influenced by their values and basic beliefs about the rights, duties and goals of all human beings. No rules, guidelines, or theories exist that cover all aspects of the ethical dilemmas that managers face. Curtin (1982) maintains that values and morals are individual, and only a person can ascertain if he or she has acted within his or her beliefs. Quinn and Smith (1987) state, in the end, ethical individuals must be prepared to live with a certain amount of ambiguity and uncertainty. The professional who accepts uncertainty in practice situation avoids the paralysis that comes from postponing action until all information is available. However, they also assert, Although there is value in learning to tolerate uncertainty, there is a point at which excessive tolerance amounts to neglect of professional and ethical commitments. To tolerate uncertainty at all times and under all circumstances is to ignore the value of knowledge and dismiss the ability to think critically. Critical thinking occurs when the manager is able to engage in an orderly process of ethical problem solving to determine the rightness or wrongness of courses of action. Learning systematic approaches to ethical decision making and problem solving reduces personal bias, facilitates decision making, and let managers feel more comfortable about decisions they have made.

ETHICAL PROBLEM SOLVING AND DECISION MAKING Much of the difficulty people have in making ethical decisions can be attributed to a lack of formal education about problem solving. Trial and error decision making helps some managers learn to make good decisions, but much is left to chance. The cost of poor ethical decisions is measured in terms of human and fiscal resources. Another error made by managers in ethical problem solving is using the outcome of the decision as the sole basis for determining the quality of the decision making. Although decision makers should be able to identify the desirable and undesirable outcomes, outcomes alone cannot be used to assess the quality of the problem solving. Many variables affect outcome, and some of these are beyond the control or foresight of the problem solver. Even the most ethical courses of action can have undesirable and unavoidable consequences. The quality of ethical problem solving should be evaluated in terms of the process used to make the decision. If a structured approach to problem solving is used, data gathering is adequate, and multiple alternatives are analyzed, even with poor outcome, the manager should accept that the best possible decision was made at that time with the information and resources available. Traditional Problem Solving Process Although not recognized specifically as an ethical problem solving model, one of the oldest and most frequently used tools for problem solving is the traditional problem solving process. This process consists of seven steps, with the actual decision being made at step five. 1. 2. 3. 4. 5. 6. 7. Identify the problem Gather data to analyze the causes and consequences of the problem Explore alternative solutions Evaluate the alternatives Select the appropriate solution Implement the solution Evaluate the results

Although many individuals use at least some of these steps in their decision making, they frequently fail to generate an adequate number of alternatives or to evaluate the results-two essential steps in the process. The Nursing Process Another problem solving model not specifically designed for ethical analysis but appropriate for it is the nursing process. Most nurses are aware of the nursing process and the cyclic nature of its component. Assessment, diagnosis, planning, implementation and

evaluation. However, most nurses do not recognize its use as a decision making tool. The cyclic nature of the process allows for feedback to occur at any step. It also allows the cycle to repeat until adequate information is gathered to make a decision. It does not, however, require clear problem identification.
Assess

Diagnose

Evaluate

Plan

Implement The MORAL Decision-Making Model Crisham (1985) has developed a model for ethical decision making incorporating the nursing process and principles of biomedical ethics. This model is especially useful in clarifying ethical problems that result from conflicting obligations. This model is represented by the mnemonic MORAL, representing the following. M----Massage the dilemma. Collect data about the ethical problem and who should be involved in the decision making process. O----Outline options. Identify alternatives; analyze the causes and consequences of each. R----Review criteria and resolve. Weigh the options against the values of those involved in the decision. This may be done through a weighting or grid. A----Affirm position and act. Develop the implementation strategy. L----Look back. Evaluate the decision making. The Murphy and Murphy Approach to Ethical Decision Making Murphy and Murphy (1976) developed a systematic approach to ethical decision making; Identify the problem Identify why the problem is an ethical problem

Identify the people involved in the ultimate decision Identify the role of the decision maker Consider the short and long term consequences of each alternative Make the decision Compare the decision with the decision makers philosophy of ethics Follow up on the results of the decision to establish a baseline for future decision making

This type of systematic decision making differs from problem solving models because it does not attempt to solve the underlying problem. It does, however, require the person to make a decision. Specifically geared toward ethical decision making, this approach helps clarify the basic beliefs and values of the people involved. ETHICAL FRAMEWORKS FOR DECISION MAKING In addition to theoretical problem solving and decision making models, managers may use ethical frameworks to guide them in solving ethical dilemmas. These frameworks do not solve the ethical problem but assist the manager in clarifying personal values and beliefs. Four of the most commonly used ethical frameworks are utilitarianism, duty based reasoning, rights-based reasoning, and intuitionism (Marquis & Huston, 1998). Using an ethical framework of utilitarianism encourages the manager to make decisions based on what provides the greatest good for the greatest number of people. Duty-based Reasoning is an ethical framework that says that some decisions must be made because there is a duty to do something. Rights-based reasoning is based on the belief that some things are a persons just due. Rights are different from needs, wants, or desires. The Intuitionist framework allows the decision maker to review each ethical problem or issue on case-to-case basis, comparing the relative weights of goals, duties and rights. This weighting is determined primarily by intuition-what the decision maker believes is right for that particular situation. Another framework managers can use for guidance in ethical problem solving is a professional code of ethics. A code of ethics is a set of principles, established by a profession, to guide the individual practitioner. PRINCIPLES OF ETHICAL REASONING

Deontological theories arise from the intent of the action that the decision maker takes. Duty-based, rights-based and intuitionist ethical reasoning derive their framework from deontological theory. Teleological theories are used to support decisions that favor the common good. Both teleological and deontological theorists developed a group of moral principles that are used for ethical reasoning. These principles of ethical reasoning further explore and define what beliefs or values form the basis for decision making. The most fundamental universal principle is respect for people. The major ethical principles stemming from this basic principle are; Autonomy (Self-Determination) A form of personal liberty, autonomy also is called freedom of choice or accepting the responsibility for ones choice. The legal right of self determination supports this moral principle. Beneficence (Doing Good) This principles state that the actions one takes should be done in an effort to promote good. The concept of nonmaleficence, which is associated with beneficence, says that if one cannot do good, then one should at least do no harm. Paternalism This principle is related to beneficence in that one person assumes the authority to make a decision for another. Because paternalism limits freedom of choice, most ethical theorists believe paternalism is justified only to prevent a person from coming to harm. Unfortunately, some managers use the principles of paternalism in subordinates career planning. In doing so, managers assume they have greater knowledge of what an employees short and long term goals should be than the employee does. Utility This principle reflects a belief in utilitarianism- what is best for the common good outweighs what is best for the individual. Utility justifies paternalism as a means of restricting individual freedom. Managers who use the principle of utility need to be careful not to become so focused on production that they become less humanistic. Justice (Treating People Fairly) This principles states that equals should be treated equally and unequals should be treated according to their differences. This principle is frequently applied when there are scarcities or competition for resources or benefits.

Veracity (Truth Telling) This principle is used to explain how people feel about the need for truth telling or the acceptability of deception. A manager who believes deception is morally acceptable if it is done with the objective of beneficence may tell all rejected job applicants that they were highly considered, whether they had been or not. Fidelity (Keeping Promises) Breaking a promise is believed by many ethicists to be wrong regardless of the consequences. In other words, even if there were no far reaching negative results of the broken promise, it is still wrong because it would render the making of any promise meaningless. However, there are times when keeping a promise may not be in the best interest of the other party. Confidentiality (Respecting Privileged Information) The obligation to observe the privacy of another and to hold certain information in strict confidence is a basic ethical principle and is a foundation of both medical and nursing ethics. However, as in deception, there are times when the presumption against disclosing information must be overridden. For example, Health care managers are required by law to report certain cases such as drug abuse in employees, elder abuse and child abuse.