A comparison of physicians' and nurses' responses to selected ethical dilemmas.

AuthorWinland-Brown, Jill E.

A Comparison of Physicians' and Nurses' Responses to Selected Ethical Dilemmas Introduction

In a perfect world, physicians and nurses practice with the same goal in mind--ethical caring for all persons served. With multiple stressors and institutional pressures present, is the moral work of healthcare getting done? In practice settings today, healthcare is not seen as moral work, but whatever needs to be done to get the job accomplished to meet the bottom line (Storch and Kenny 2007). In a list of priorities, moral work would come at the end. Anyone in a health care setting recently knows that it's in chaos. Ethical dilemmas abound. Everyone expects healthcare workers to act at a Ghandian level of moral reasoning. Certainly patients expect this and have every right to.

Professional experiences and personal values in prior studies influenced the attitudes of physicians and nurses when pondering ethical dilemmas. Research has shown that nurses are more concerned about the inappropriate use of end-of-life treatment than physicians (Carmel, et al. 2007). This study also showed that the law was the driving force for nurses and that they placed more importance on autonomy, while patients' wishes were the most important factor for physicians. Of note is that most nurses are institutional employees where legal norms are expected. Physicians have more difficulty with dealing with psychosocial and spiritual care at patients' end-of-life, and religion was more important to nurses (Carmel, et al. 2007).

With much conflicting information regarding physicians' and nurses' reactions to ethical situations, the current study was conducted to compare their choices to four selected dilemmas. Responses to the dilemmas reflect different ethical principles. Reasoning using ethical principles as a guide reflects reasoning at a principled level, the highest level in moral development.

Review of Literature

Moral Development

Lawrence Kohlberg, the Father of Moral Development, used Piaget's cognitive-development approach to analyze the different ways that individuals perceive themselves in the social world. Like Piaget, Kohlberg saw moralization as a process of internalization of cultural or parental norms (Kohlberg 1976). Kohlberg identified six stages of moral development, encompassing three levels, through which an individual progresses in developing principled moral thinking as shown in Table 1. The third postconventional level (Stages 5 and 6) is the Principled level and may occur after age 20 in a minority of adults. A person at this level attempts to clearly define universal moral values in terms of self-chosen principles. In health care, those principles include autonomy, beneficence, nonmaleficence, justice, veracity, fidelity, and justice. The stages of moral development are hierarchical and attainment of each stage of moral judgment is prerequisite to attainment of the next higher stage (Kohlberg 1976). Movement to the next step of development rests not only on exposure to the next level of thought, but to experiences of conflict of the individual's current level of thought with ethical situations (Kohlberg and Blatt, 1973, 4). Higher state reasoning is assimilated only if cognitive conflict is stimulated. Moral reasoning at a stage higher than one's own leads to increased moral thinking at the next higher stage, only if it disagrees with, or introduces uncertainty into, the individual's own decision on moral dilemmas (Kohlberg and Blatt 1973,5; Rest, Turiel, and Kohlberg 1969, 237).

The majority of adults in American society use conventional (Stages 3 and 4) moral judgment (Rest, Turiel, and Kohlberg, 1969, 241; Kohlberg 1981). Kohlberg's stages do not reflect the outright decision of the individual, but the reasons which reflect how one reached the decision. While Kohlberg's theory does not predict what action a person will take, it does serve to clarify ethical reasoning, which permits more effective discussion of moral issues. The ethical theories which correspond to each of Kohlberg's levels tend to move from egoistic to altruistic concerns (Allen and Fowler, 1982, 20).

Gilligan (1977, 1982) who studied with Kohlberg questioned his research findings as they were focused solely on males. She found that the moral reasoning and development of women and men differed. Her research showed that women placed more importance on relationships and caring for themselves and others rather than rules and principles. Gilligan's theory on women focused on care considerations. In a research study by Peter and Gallop (1994), it was found that the differences between nursing students and medical students were not related to position, but rather to gender. Females used care considerations more frequently than males.

Ethical reasoning of physicians and nurses

Almost thirty years ago, nursing theorists Crisham (1981) and Ketefian (1981) showed the significance of formal education in improving one's moral reasoning abilities. The higher the educational level, the higher the level of moral development. Autonomy is usually cited as the most important principle held by nurses. Carmel et al.'s (2007) study found that physicians rated personal autonomy or patients' wishes higher than nurses. The authors stated that one reason might be that physicians are more autonomous and the decision makers, whereas nurses perceive the law as the driving force and follow physicians' orders. These nurses were all working in institutions where convention is the rule. de Casterle's (2008) study used Kohlberg's stages of moral development and found that while nurses tended to use conventions as their predominant decision-guiding criteria (which is stage 4); nurses in general evaluate stage 5 statements as most important arguments in making an ethical decision. Stage 5 is the first of two stages in the postconventional or principled level of moral development. Other studies show that nurses are in stage 3 (Kudzma 1980; Aroskar 1982). Seventy percent of all Americans reason at the conventional level of moral reasoning which is stage 3 or 4. Nurses tend to use conventions or laws to guide their decision making in ethical dilemmas rather than patients' personal needs. (Carmel, et al. 2007; de Casterle, et al. 2008).

Oberle and Hughes (2001) conducted a small qualitative study comparing physicians and nurses perceptions of ethical problems and found that the differences were a function of the professional role rather than differences in moral reasoning. They cited that while physicians make the decisions, nurses must live with the ultimate decision. In a historical article regarding nurses and physicians in the nineteenth century, Nolte (2008) shares that physicians were always responsible for truth telling (fidelity) to patients but that nurses were able to circumvent some of these 'rules' as they were perceived as being responsible for the spiritual care of patients. With this in mind, nurses were able to share information with patients related to meeting their spiritual needs, superseding physicians' wishes.

Moral distress

Moral distress has been prevalent for decades. The first author to discuss this was probably Jameton (1984) with his seminal work more than 25 years ago. A new nursing diagnosis for moral distress was listed as of 2007. Moral discomfort is extreme discomfort in a patient care situation that results when one knows what one ought to do, but because of internal or external constraints, ends up doing what one knows is morally wrong (Corley, 2002; Pendry, 2007; Badger and O'Connor 2006). The discomfort may affect mind, body, spirit, or relationships. Many nurses leave the profession because of the inability to handle this added moral stress to everyday home and work stress (Pendry 2007).

Tools have been developed to measure moral distress (Corley et al. 2001; Sporrong...

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