Upon completion of this course, you will be able to:
Discuss ethical theories and principles as they relate to pain management.
Explain the concept of an ethical dilemma and how it relates to the management of pain.
Compare the ethical codes of the American Nurses Association and the International Council of Nurses.
Explain the relationship of ethics to law.
Discuss laws that control the manufacture and distribution of drugs.
Because pain is the most common reason people seek medical care, its management is one of the most important functions of healthcare providers. For this reason, understanding ethical principles and legal issues as they apply to pain is essential for every caregiver.
Ethics: A Branch of Philosophy
Many people roll their eyes and change the subject when they hear the word ethics, viewing it as too controversial or too complex to discuss freely. Nonetheless, ethics is a significant concern of thinking, caring persons, especially nurses who manage the care of people in pain.
Ethics is the branch of philosophy concerned with the rightness or wrongness of human behavior and the goodness or badness of its effects. Ethics assumes that people have the ability to make choices about their behavior. For that reason it has been the subject of philosophical discussion for centuries and has generated an enormous body of literature. Students of ethics have divided these writings into three general categories: descriptive (characterizing), analytical (metaethics), and prescriptive (normative).
Descriptive ethics reports and describes the moral choices people make.
Analytical ethics scrutinize the language people use to discuss issues of right and wrong.
Prescriptive ethics offers advice about how people should decide what is good or bad behavior. It does this from two very different perspectives: teleological and deontological.
A teleological (consequential, utilitarian, situational) perspective affirms that the rightness or wrongness of an act is determined by the end results of an action. The term comes from the Greek teleos, meaning "end." If the end result harms others, the act is considered wrong or bad. If the end result benefits others, the act is considered good or right. The central issue of this perspective is the principle of the "greatest good." The utilitarian teachings of John Stuart Mill and the situation ethics teachings of Joseph Fletcher maintain that end results and circumstances are essential factors in considering the rightness or wrongness of any human behavior (Hamilton, 1996).
Teleological theories foster morality by developing the capacity of humans to make choices. These theories reject fixed moral rules of conduct such as the biblical command "Thou shalt not kill" (Exodus 20:13). For example, a man is suffering with intractable pain caused by an incurable disorder. He begs his physician to perform a surgical procedure that will relieve his suffering but might hasten his death. According to teleological perspective, the physician should perform the surgery because the end result (relieving pain) is a greater good than keeping the man alive with intractable pain.
The deontological (nonconsequentialist) perspective fosters morality by teaching humans to accept and obey fixed laws. The term comes from the Greek deontos, meaning "duty to obey." Immanuel Kant is the theorist most often identified with deontological ethics. He maintained that certain acts are inherently right or wrong, regardless of the situation or the end results. In deontological ethics, there are no exceptions or mitigating circumstances. According to this perspective, preserving the life of the man with intractable pain is a greater good than relieving his pain and hastening his death. The physician's duty is to obey the commandment "Thou shalt not kill" regardless of the situation or end results. Thus, the deontological perspective simplifies ethical decision-making by removing the issue of mitigating circumstances.
Bioethics and Related Concepts
Bioethics is the application of ethics to matters of human life. As scientific knowledge expands and healthcare providers have greater control over pain and pain relief, life and death, it is vital that nurses address issues of right and wrong behavior.
Although some authors use the term morals to refer to human behavior and ethics to refer to formalized codes of conduct, both words mean the same thing. Ethics comes from the Greek word ethos and morals from the Latin word mores. In recent years, some politicians have substituted the word values for morality; however the word values has a much broader meaning.
Values are treasured ideals or attributes, such as creativity, achievement, adventure, power, friendship, and belief systems. Understanding one's values brings purpose and clarity to life. The desirability of such clarity was recognized by Socrates, who is credited with saying, "An unexamined life is not worth living." To help people examine their lives and clarify their values, Louis Raths (1979) suggested a seven-step process that he called "values clarification" (see box).
THE VALUING PROCESS
Identifying and selecting alternatives
Choosing freely from alternatives
Considering the consequences of each choice
Being proud of and happy in one's choice
Affirming one's choice publicly
Making the choice a part of one's behavior
Acting with a pattern of consistency and repetition
Source: Modified from Raths et al., 1979.
Belief systems are organized patterns of thought regarding the origin, purpose, and place of humans in the universe. These systems seek to explain the mysteries of life and death, good and evil, health and illness. Typically, belief systems include an ethical code of conduct about how people should relate to the world and its inhabitants.
Religions are patterns of thought and action that typically include belief systems, devotional rituals, organizational structures, and faith in a mystical power. Often, however, people develop their own belief systems, independent of organized religions.
Ethical principles are fundamental concepts by which people judge behavior. These principles help individuals make decisions and serve as criteria against which they measure behavior. Laws, on the other hand, are rules made by an authority with the power to enforce them. Although laws flow from ethical principles, they are limited to specific situations and codified by detailed language. Ethical principles, on the other hand, are guiding ideals of conduct that speak to the spirit of a law, not necessarily to its letter.
Throughout recorded history, leaders of world religions have taught an overarching ethical principle commonly called the Golden Rule: "Do unto others as you would they do unto you." Some philosophers emphasize certain principles over others: Kant held that duty was the central issue; Mills, the interest of all; Fletcher, love; Thiroux, human dignity; Nodding, care; and Gilligan, care and justice. A single, global principle for ethical behavior is an attractive approach, but when people face real-life situations, they seek more precise guidance. Over the years, five ethical principles have emerged as especially applicable to nursing. They include 1) respect for human life and dignity, 2) beneficence, 3) autonomy, 4) honesty, and 5) justice. These principles take on special significance as we consider the management of pain.
RESPECT FOR HUMAN LIFE AND DIGNITY
Respect for human life and dignity is one of the most basic of ethical principles. It requires that "individuals be treated as unique and equal to every other individual and that special justification is required for interference with an individual's own purposes, privacy, and behavior" (Rawls, 1971). This ethical principle elevates respect for the life, freedom, and privacy of all humans. Thiroux says this principle is necessary for any moral system because "there can be no human being, moral or immoral, if there is no human life" (1990). When applied to pain management, respect for human life and dignity means nurses:
Attend to every report of pain by clients or their families.
Regard the personal privacy of clients as they deal with pain.
Respect the lifestyle, personhood, and belief systems of clients.
Strive to sustain human life and dignity while relieving pain and suffering.
Beneficence means doing good to benefit others. Although some writers separate beneficence (doing good) from nonmalfeasance (not doing harm), Frankena (1973) suggested the ethical principle of beneficence represents a continuum from not harming to doing good, specifically: 1) not inflicting harm, 2) preventing harm, 3) removing harm, and 4) promoting and doing good.
For nurses, beneficence means more than providing technically competent client care. It means acting in ways that demonstrate genuine and accurate empathy, providing nonpossessive warmth, listening, empathizing, supporting, and nurturing. In fact, the central task of nursing—its very essence—is doing good for others. When applied to pain management, beneficence means nurses:
Believe clients when they report pain.
Carefully assess their level of pain.
Provide timely, appropriate interventions to relieve pain.
Accurately evaluate the effectiveness of an intervention.
Communicate the effectiveness of interventions to other healthcare members.
Give clients nonpossessive warmth, accurate empathy, and unconditional positive regard.
Autonomy is the right of self-determination, independence, and freedom. It is the personal right of individuals to absorb information, comprehend it, make a choice, and carry out their choice. Nurses demonstrate the principle of autonomy when they provide accurate information to clients, help them comprehend it, and respect the decisions they make as a result of their understanding. When applied to pain management, autonomy means nurses:
Inform clients about available options for pain management.
Make sure clients fully understand the actions and risks of pain-relieving options.
Allow clients enough time to consider pain-relieving alternatives.
Accept decisions clients make regarding management of their pain.
Implement and evaluate pain-relieving interventions chosen by clients.
Honesty means communicating the truth in word and deed. Even when nurses must convey unwelcome information to clients about an illness, injury, or treatment option, they must do so truthfully. Withholding information from clients is appropriate only when they are minor children or adults who require a legal guardian. When applied to pain management, the ethical principle of honesty means nurses:
Provide factual information about treatment options, including benefits and risks.
Use language that is clear and appropriate to the age and capacity of the client.
Encourage client participation in pain-management decisions.
Convey genuine concern when giving unwelcome information.
Report and record critical data accurately, regardless of personal consequences.
Justice implies fairness and equality. It requires impartial treatment of clients. Like other ethical principles, justice is based on respect for human life and dignity. The traditional image of justice is a blindfolded woman with a scale, weighing an issue on the basis of objective evidence and judicial precepts. Justice means that scarce resources are distributed equally, using the same criteria for everyone. When applied to pain management, the ethical principle of justice means nurses:
Attend to complaints of pain by clients, no matter how difficult they may be.
Assess pain and intervene to relieve pain with equal diligence for all clients.
Evaluate and communicate information about pain with fairness and lack of bias.
A dilemma is a perplexing problem that requires a choice between conflicting alternatives. An ethical dilemma is a moral problem that requires a choice between two or more opposite actions, each of which is based on an ethical principle.
Example 1. A nurse must decide whether to honor the principle of autonomy and disclose the risk of a proposed treatment for pain or to honor the principle of beneficence and withhold information in order to reduce the client's anxiety. (See the preceding sections "Autonomy" and "Beneficence.")
Example 2. An elderly woman is worried that she is becoming an "addict" because she needs so much pain medicine. The nurse must decide whether to honor the principle of honesty and immediately tell her that she may develop "drug tolerance" or to honor the principles of respect for human dignity and wait until the woman has less pain to explain that she will be weaned from the drug gradually with reduced doses. (See the preceding sections "Honesty" and "Respect for Human Life and Dignity.")
Resolution of ethical dilemmas requires careful evaluation of all the facts of the case, consultation with all concerned parties, and appraisal of the decision-makers' ethical stance (whether it is teleological, considering end results, or deontological, obeying fixed laws of behavior).
Nowadays, ethical dilemmas in healthcare facilities arise more frequently because modern medicine can keep hearts and lungs functioning much longer than thinking brains. To help resolve these perplexing issues, many institutions appoint ethics committees made up of healthcare professionals, ethicists, lawyers, and clergy. The task of ethics committees is to help decision-makers resolve ethical dilemmas using an ethical decision-making process such as the following:
Gather relevant facts about the client's age, diagnosis, and circumstances and the ethical stance of the decision-maker (deontological or teleological)
Identify and clearly state the problem
List alternative actions, together with ethical principles that support each action
Determine who can make the decision and assist that person to make it
Provide emotional support to all involved parties
In support of the ethical principle of autonomy and to reduce ethical dilemmas, the Joint Commission on Accreditation of Healthcare Organizations recommends that all adults discuss their wishes regarding artificial life-support and sign a legal document called an Advance Healthcare Directive appointing someone to make healthcare decisions in their stead if they should become incapacitated (JCAHO, 2009).
Codes of Ethics
Codes of ethics are formal statements that set standards of ethical behavior for groups of people. In fact, one of the hallmarks of a profession is a code of ethics to which its members subscribe. For instance, the American Nurses Association's (ANA) Code of Ethics for Nurses with Interpretive Statements (see box) and the International Council of Nurses' (ICN) Code of Ethics for Nurses (see box) make explicit the goals and values of the profession and provide guidance for carrying out nursing responsibilities.
AMERICAN NURSES ASSOCIATION (ANA) CODE OF ETHICS
The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.
The nurse's primary commitment is to the client, whether an individual, family, group, or community.
The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the client.
The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum client care.
The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.
The nurse participates in establishing, maintaining, and improving healthcare environments and conditions of employment conducive to the provision of quality healthcare and consistent with the values of the profession through individual and collective action.
The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.
The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs.
The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.
Source: ANA, 2001.
INTERNATIONAL COUNCIL OF NURSES (ICN)
CODE OF ETHICS FOR NURSES
Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health, and to alleviate suffering. The need for nursing is universal.
Inherent in nursing is respect for human rights, including the right to life, to dignity, and to being treated with respect. Nursing care is unrestricted by considerations of age, color, creed, culture, disability or illness, gender, nationality, politics, or social status.
Nurses render health services to the individual, the family, and the community and coordinate their services with those of related groups.
ELEMENTS OF THE CODE
Nurses and People
The nurse's primary responsibility is to those people requiring nursing care.
In providing care, the nurse promotes an environment in which the human rights, values, customs, and spiritual beliefs of the individual, family, and community are respected.
The nurse ensures that the individual receives sufficient information on which to base consent for care and related treatment.
The nurse holds in confidence personal information and uses judgment in sharing this information.
The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations.
The nurse also shares responsibility to sustain and protect the natural environment from depletion, pollution, and degradation and destruction.
Nurses and Practice
The nurse carries personal responsibility and accountability for nursing practice and for maintaining competence by continual learning.
The nurse maintains a standard of personal health such that the ability to provide care is not compromised.
The nurse uses judgment regarding individual competence when accepting and delegating responsibility.
The nurse at all times maintains standards of personal conduct which reflect well on the profession and enhance public confidence.
Nurses and the Profession
The nurse assumes the major role in determining and implementing acceptable standards of critical nursing practice, management, research, and education.
The nurse is active in developing a core of research-based professional knowledge.
The nurse, acting through the professional organization, participates in creating and maintaining equitable social and economic working conditions in nursing.
Nurses and Coworkers
The nurse sustains a cooperative relationship with coworkers in nursing and other fields.
The nurse takes appropriate action to safeguard individuals when their care is endangered by a coworker or any other person.
Source: International Council of Nurses, 2006.
There are many modalities in the pain management arsenal, such as massage, exercise, sleep, meditation, hypnosis, acupuncture, hydrotherapy, and drugs. Laws and regulations that insure the usefulness and safety of these measures are concerns of both the federal and state government. In general, the federal government regulates drugs, foods, and medical devises that cross state lines, and the states regulate products that originate within their borders. In addition, the states license the professionals who administer pain management remedies.
Federal Pharmaceutical Legislation
Drugs constitute one of the most effective and often-used weapons against pain. Until the beginning of the twentieth century, no federal rules or regulations protected consumers from ineffective or harmful drugs. After several drug-induced tragedies, the U.S. Congress passed the Pure Food and Drug Act of 1906. This act recognized the United States Pharmacopeia, a publication that lists drugs that met certain standards for dosage, therapeutic use, client safety, quality, purity strength, and packaging. These drugs were called "official" and were permitted to print "USP" after the name of the drug. This act also empowered the federal government to take legal action against manufacturers of drugs that did not comply with the stated standards. Since then, many laws have been passed to ensure the safety and effectiveness of drugs. The following table lists some of the most important pieces of federal legislation.
Controlled Substance Act
In 1971, in response to the growing misuse and abuse of drugs in the 1960s, Congress passed the Comprehensive Drug Abuse, Prevention, and Control Act. Known as the Controlled Substance Act, the legislation is of particular concern to healthcare professionals concerned with the management of pain. The act created a schedule of controlled substances, ranking them according to their potential for abuse. Specifically, it identified five categories or schedules of drugs, from those with the highest abuse potential (C-I) to those with the lowest abuse potential (C-V) as shown in the table below.
State Pharmaceutical Legislation
Legislative bodies of the states and territories also pass laws regulating the manufacture and distribution of food, drugs, and medical devices. This authority is derived from the Tenth Amendment to the United States Constitution, which says, "The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people." Of special concern to nurses are laws that affect the management of pain, and in recent times, laws that authorize the medicinal use of marijuana.
Marijuana is made from the chopped leaves and flowers of the Cannabis sativa plant, a native of East India. It is grown for its fiber (hemp) and resin, which contains the active ingredient cannabinol. Since ancient times the plant has been chewed, smoked, and drunk by people everywhere in the world for its psychic effects. The drug produces a calm, mildly euphoric state with slowed reaction time, heightened sensations, and distorted time perception. Long-term use does not seem to cause physiologic dependence but may cause psychological dependence and lung damage from smoke inhalation. The chemical tetrahydrocannabinol (THC) is synthesized and marketed as the drug dronabinol (Marinol). Its two approved uses are to treat: (1) anorexia associated with weight loss in clients with HIV-AIDS, and (2) nausea and vomiting associated with cancer chemotherapy (Unimed Pharmaceuticals, 2001).
Because of vigorous enforcement of the Controlled Substance Act by the federal Drug Enforcement Administration (DEA) and harsh penalties imposed on individuals who use marijuana, many states have passed laws asserting their right to regulate drugs within their borders. These laws remove state-level criminal penalties on the use, possession, and cultivation of marijuana for medicinal purposes. Although the laws differ, most require a physician's diagnosis and recommendation, registration of the user, and limitation of the amount of marijuana a person may grow or possess (Drug Policy Research Center, 2009).
State Professional Legislation
It is the responsibility of every state and territory of the United States to regulate the health and safety of their citizens. To do this, they pass laws such as the Nurse Practice Act. In these acts they define the scope of practice in their state of each category of healthcare, such as medicine, nursing, acupuncture, and physical therapy. Typically, an administrative board writes rules and regulations to ensure that the provisions of the act are carried out. These regulations include such issues as schools, licensure, disciplinary proceedings, continuing education, and advance practice. By so doing, the states protect citizens and advance safe pain management practice.
By applying the ethical principles of respect for human life and dignity, beneficence, autonomy, honesty, and justice to the management of pain, nurses fulfill one of their most vital functions. By following federal and state laws regulating drugs, medical devices, and professional practice, they provide safe and dependable care for those who suffer pain.