Nursing Archives - Protection of Conscience Project Library

Nurses’ use of conscientious objection and the implications for conscience

Christina Lamb, Marilyn Evans, Yolanad Babenko-Mould, Carol Wong, Ken Kirkwood

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Aims: To explore the meaning of conscience for nurses in the context of conscientious objection (CO) in clinical practice. Design: Interpretive phenomenology was used to guide this study.

Data sources: Data were collected from 2016 ‐ 2017 through one‐on‐one interviews from eight nurses in Ontario. Iterative analysis was conducted consistent with interpretive phenomenology and resulted in thematic findings. Review methods: Iterative, phased analysis using line‐by‐line and sentence highlighting identified key words and phrases. Cumulative summaries of narratives thematic analysis revealed how nurses made meaning of conscience in the context of making a CO.

Impact: This is the first study to explore what conscience means to nurses, as shared by nurses themselves and in the context of CO. Nurse participants expressed that support from leadership, regulatory bodies, and policy for nurses’ conscience rights are indicated to address nurses’ conscience issues in practice settings.

Results: Conscience issues and CO are current, critical issues for nurses. For Canadian nurses this need has been recently heightened by the national legalization of euthanasia, known as Medical Assistance in Dying in Canada. Ethics education, awareness, and respect for nurses’ conscience are needed in Canada and across the profession to support nurses to address their issues of conscience in professional practice.

Conclusion: Ethical meaning emerges for nurses in their lived experiences of encountering serious ethical issues that they need to professionally address, by way of conscience‐based COs.

Lamb C, Evans M, Babenko-Mould Y, Wong C, Kirkwood Ken. Nurses’ use of conscientious objection and the implications for conscience. J Adv Nurs 2018 Oct 16. doi: 10.1111/jan.13869

Conscientious objection to participation in abortion by midwives and nurses: a systematic review of reasons

Valerie Fleming Lucy Frith, Ans Luyben, Beate Ramsayer

Abstract
Background: Freedom of conscience is a core element of human rights respected by most European countries. It allows abortion through the inclusion of a conscience clause, which permits opting out of providing such services. However, the grounds for invoking conscientious objection lack clarity. Our aim in this paper is to take a step in this direction by carrying out a systematic review of reasons by midwives and nurses for declining, on conscience grounds, to participate in abortion.

Method: We conducted a systematic review of ethical arguments asking, “What reasons have been reported in the argument based literature for or against conscientious objection to abortion provision by nurses or midwives?” We particularly wanted to identify any discussion of the responsibilities of midwives and nurses in this area. Search terms were conscientious objection and abortion or termination and nurse or midwife or midwives or physicians or doctors or medics within the dates 2000–2016 on: HEIN legal, Medline, CINAHL, Psychinfo, Academic Search Complete, Web of Science including publications in English, German and Dutch. Final articles were subjected to a rigorous analysis, coding and classifying each line into reason mentions, narrow and broad reasons for or against conscientious objection.

Results: Of an initial 1085 articles, 10 were included. We identified 23 broad reasons, containing 116narrow reasons and 269 reason mentions. Eighty one (81) narrow reasons argued in favour of and 35 against conscientious objection. Using predetermined categories of moral, practical, religious or legal reasons, “moral reasons” contained the largest number of narrow reasons (n = 58). The reasons and their associated mentions in this category outnumber those in the sum of the other three categories.

Conclusions: We identified no absolute argument either for or against conscientious objection by midwives or nurses. An invisibility of midwives and nurses exists in the whole debate concerning conscientious objection reflecting a gap between literature and practice, as it is they whom WHO recommend as providers of this service. While the arguments in the literature emphasize the need for provision of conscientious objection, a balanced debate is necessary in this field, which includes all relevant health professionals.

Fleming V, Frith L, Luyben A, Ramsayer B. Conscientious objection to participation in abortion by midwives and nurses: a systematic review of reasons. BMC Medical Ethics. 2018;19:31. doi:10.1186/s12910-018-0268-3.

Nurses’ perspectives on whether medical aid in dying should be accessible to incompetent patients with dementia: findings from a survey conducted in Quebec, Canada

G. Bravo, C. Rodrigue, M. Arcand, J. Downie, M.-F. Dubois, S. Kaasalaine, C.M. Hertogh,S. Pautex, L. Van den Block

Abstract
We conducted a survey in a random sample of 514 Quebec nurses caring for the elderly to assess their attitudes towards extending medical aid in dying to incompetent patients and to explore associated factors. Attitudes were measured using clinical vignettes featuring a hypothetical patient with Alzheimer disease. Vignettes varied according to the stage of the disease (advanced or terminal) and the presence or absence of a written request. Of the 291 respondents, 83.5% agreed with the current legislation that allows physicians to administer aid in dying to competent patients who are at the end of life and suffer unbearably. A similar proportion (83%, p = 0.871) were in favor of extending medical aid in dying to incompetent patients who are at the terminal stage of Alzheimer disease, show signs of distress, and have made a written request before losing capacity.

Bravo G, Rodrigue C, Arcand M, Downie J, Dubois M-F, Kaasalaine S, Hertogh CM, Pautex S, L. Van den Block L. Nurses’ perspectives on whether medical aid in dying should be accessible to incompetent patients with dementia: findings from a survey conducted in Quebec, Canada. Geriatr Nurs. 2018 Jan 3. pii: S0197-4572(17)30319-1. doi: 10.1016/j.gerinurse.2017.12.002.

Fostering Nurses’ Moral Agency and Moral Identity: The Importance of Moral Community

Joan Liaschenko, Elizabeth Peter

Abstract:
It may be the case that the most challenging moral problem of the twenty-first century will be the relationship between the individual moral agent and the practices and institutions in which the moral agent is embedded. In this paper, we continue the efforts that one of us, Joan Liaschenko, first called for in 1993, that of using feminist ethics as a lens for viewing the relationship between individual nurses as moral agents and the highly complex institutions in which they do the work of nursing. Feminist ethics, with its emphasis on the inextricable relationship between ethics and politics, provides a useful lens to understand the work of nurses in context. Using Margaret Urban Walker’s and Hilde Lindemann’s concepts of identity, relationships, values, and moral agency, we argue that health care institutions can be moral communities and profoundly affect the work and identity and, therefore, the moral agency of all who work within those structures, including nurses. Nurses are not only shaped by these organizations but also have the power to shape them. Because moral agency is intimately connected to one’s identity, moral identity work is essential for nurses to exercise their moral agency and to foster moral community in health care organizations. We first provide a brief history of nursing’s morally problematic relationship with institutions and examine the impact institutional master narratives and corporatism exert today on nurses’ moral identities and agency. We close by emphasizing the significance of ongoing dialogue in creating and sustaining moral communities, repairing moral identities, and strengthening moral agency.

Liaschenko J, Peter E. Fostering Nurses’ Moral Agency and Moral Identity: The Importance of Moral Community. The Hastings Center Report, Volume 46, Issue S1, September/October 2016, Pages S18–S21.

Beneficent Voluntary Active Euthanasia: A Challenge to Professionals Caring for Terminally Ill Patients

Ann-Marie Begley

Abstract
Euthanasia has once again become headline news in the UK, with the announcement by Dr Michael Irwin, a former medical director of the United Nations, that he has helped at least 50 people to die, including two between February and July 1997. He has been quoted as saying that his ‘conscience is clear’ and that the time has come to confront the issue of euthanasia.

For the purposes of this article, the term ‘beneficent voluntary active euthanasia’ (BVAE) will be used: beneficent from the prima facie principle of beneficence, to do good, and voluntary to indicate that this must be carried out at the request of a competent client. This implies adherence to another prima facie principle, that of respect for autonomy. Active implies that something is done or given with the intention of hastening death. The word euthanasia itself simply means ‘good death’.

This article examines the moral positions of two nurses and one junior doctor towards the subject of BVAE and an attempt is made to represent the main conflicting moral positions. The central arguments against BVAE and counterarguments are presented. The conclusion reached is that consenting adults should not be prevented from availing themselves of BVAE if another consenting adult (a medical doctor) is available and capable of carrying out their wishes. This being the case, it is suggested that BVAE should be available as an option in hospices and in the community.

The aims of this article are: to generate debate among professionals; to present a three-way discussion that might be useful as a focus for educational purposes, particularly at undergraduate level; to challenge professionals to confront the issue of euthanasia; and to plead the case of those who request assistance in exercising autonomy by gaining control over their own deaths.

Begley A-M. Beneficent Voluntary Active Euthanasia: A Challenge to Professionals Caring for Terminally Ill Patients. Nurs Ethics. 1998;5(4):294-306.

Meeting ethical challenges in acute nursing care as narrated by registered nurses

Venke Sørlie, Annica Kihlgren, Mona Kihlgren

Abstract
Five registered nurses were interviewed as part of a comprehensive investigation by five researchers into the narratives of five enrolled nurses (study 1, published in Nursing Ethics 2004), five registered nurses (study 2) and 10 patients (study 3) describing their experiences in an acute care ward at one university hospital in Sweden. The project was developed at the Centre for Nursing Science at Örebro University Hospital. The ward in question was opened in 1997 and provides care for a period of up to three days, during which time a decision has to be made regarding further care elsewhere or a return home. The registered nurses were interviewed concerning their experience of being in ethically difficult care situations in their work. Interpretation of the theme ‘ethical problems’ was left to the interviewees to reflect upon. A phenomenological hermeneutic method (inspired by the French philosopher Paul Ricoeur) was used in all three studies. The most prominent feature revealed was the enormous responsibility present. When discussing their responsibility, their working environment and their own reactions such as stress and conscience, the registered nurses focused on the patients and the possible negative consequences for them, and showed what was at stake for the patients themselves. The nurses demonstrated both directly and indirectly what they consider to be good nursing practices. They therefore demand very high standards of themselves in their interactions with their patients. They create demands on themselves that they believe to be identical to those expected by patients.

Sørlie V, Kihlgren A, Kihlgren M. Meeting ethical challenges in acute nursing care as narrated by registered nurses. Nurs Ethics. 2005;12(2):133-142.

Nurses’ Participation in the Euthanasia Programs of Nazi Germany

Susan Benedict,Jochen Kuhla

Abstract
During the Nazi era, so-called euthanasia programs were established for handicapped and mentally ill children and adults. Organized killings of an estimated 70,000 German citizens took place at killing centers and in psychiatric institutions. Nurses were active participants; they intentionally killed more than 10,000 people in these involuntary euthanasia programs. After the war was over, most of the nurses were never punished for these crimes against humanity-although some nurses were tried along with the physicians they assisted. One such trial was of 14 nurses and was held in Munich in 1965. Although some of these nurses reported that they struggled with a guilty conscience, others did not see anything wrong with their actions, and they believed that they were releasing these patients from their suffering.

Benedict S, Kuhla J. Nurses’ Participation in the Euthanasia Programs of Nazi Germany. West J Nurs Res. 1999;21(2).

Palliative care professionals’ willingness to perform euthanasia or physician assisted suicide

Julia Zenz, Michael Tryba, Michael Zenz

Abstract
Background: Euthanasia and physician assisted suicide (PAS) are highly debated upon particularly in the light of medical advancement and an aging society. Little is known about the professionals’ willingness to perform these practices particularly among those engaged in the field of palliative care and pain management. Thus a study was performed among those professionals.

Methods: An anonymous questionnaire was handed out to all participants of a palliative care congress and a pain symposium in 2013. The questionnaire consisted of 8 questions regarding end of life decisions. Proposed patient vignettes were used.

Results: A total of 470 eligible questionnaires were returned, 198 by physicians, 272 by nurses. The response rate was 64 %. The majority of professionals were reluctant to perform euthanasia or PAS: 5.3 % of the respondents would be willing to perform euthanasia on a patient with a terminal illness if asked to do so. The reluctance grew in case of a patient with a non-terminal illness. The respondents were more willing to perform PAS than euthanasia. Nurses were more reluctant to take action as opposed to the physicians. The majority of the respondents would attempt to treat the patient’s symptoms first before considering life-ending measures. As regards any decision making process the majority would consult with a colleague.

Conclusions: This is the first German study to ask about the willingness of professionals to take action as regards euthanasia and PAS without biased phrasing. As opposed to the general acceptance that is respectively high, the actual willingness to perform life-ending measures is low. The German debate on physician assisted suicide and its possible legalization should also incorporate clarifications regarding the responsibility who should eventually perform these acts.

Zenz J, Tryba M, Zenz M. Palliative care professionals’ willingness to perform euthanasia or physician assisted suicide. BMC Palliative Care. 2015 Nov 14;14(1).

Ethical Issues Experienced by Hospice and Palliative Nurses

Jooyoung Cheon, Nessa Coyle, Debra L. Wiegand, Sally Welsh

Abstract
Nurses encounter ethical dilemmas in their clinical practice especially those associated with palliative and end-of-life care. The Hospice and Palliative Nurses Association (HPNA) members were asked to participate in an ethics survey. The survey aimed to identify ethical issues experienced by hospice and palliative nurses, identify resources available to them and barriers if any to their use, and to identify how HPNA can be of support to hospice and palliative nurses.

One hundred twenty-nine (n = 129) HPNA members completed the online survey. The information from each of the surveys was carefully reviewed, and responses were collapsed into 6 themes.

The ethical dilemmas included inadequate communication, provision of nonbeneficial care, patient autonomy usurped/threatened, issues with symptom management and the use of opioids, issues related to decision making, and issues related to discontinuing life-prolonging therapies.

Approximately two-thirds of the nurses used resources in an attempt to resolve the ethical issues, including a formal ethics consultation, involvement of the palliative/hospice team, consulting with other professionals, and use of educational resources.

One-third of the nurses said there were institutional or personal barriers that prevented the ethical dilemma from being resolved. Participants suggested ways that HPNA could help them to effectively manage ethical dilemmas.

Cheon J, Coyle N, Wiegand DL, Welsh S. Ethical Issues Experienced by Hospice and Palliative Nurses. J Hospice and Palliative Nursing. 2015;17(1):7-13.

Professional QOL of Japanese nurses/midwives providing abortion/childbirth care

M. Mizuno, E. Kinefuchi, R. Kimura

Abstract
This study explored the relationship between professional quality of life and emotion work and the major stress factors related to abortion care in Japanese obstetric and gynecological nurses and midwives. . . . Multiple regression analysis revealed that of all the evaluated variables, the Japanese version of the Frankfurt Emotional Work Scale score for negative emotions display was the most significant positive predictor of compassion fatigue and burnout. The stress factors “thinking that the aborted fetus deserved to live” and “difficulty in controlling emotions during abortion care” were associated with compassion fatigue. These findings indicate that providing abortion services is a highly distressing experience for nurses and midwives.

Mizuno M, Kinefuchi E, Kimura R. Professional QOL of Japanese nurses/midwives providing abortion/childbirth care. Nurs Ethics January 17, 2013 0969733012463723