NR360 Informatic Systems In Healthcare
Reflection
Write a 50-word reflection demonstrating your understanding of how effective nursing care improves patient outcomes related to the selected topic.
Nurse’s Touch – Nursing Informatics & Technology: Virtual Social Networks
EBOOK: McGonigle, D. & Mastrian, K. (2018). Nursing informatics and the foundation of knowledge (4th ed.). Jones & Bartlett.
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APA format
Theoretical approaches to healthcare ethics have
evolved in response to societal changes. In a 30-year
retrospective article for the Journal of the American
Medical Association, Pellegrino (1993) traced the
evolution of healthcare ethics from the Hippocratic
ethic, to principlism, to the current antiprinciplism
movement.
The Hippocratic tradition emerged from relatively
homogenous societies where beliefs were similar and
most societal members shared common values. The
emphasis was on duty, virtue, and gentlemanly
conduct. NR360 Informatic Systems In Healthcare.
Principlism arose as societies became more
heterogeneous and members began experiencing a
diversity of incompatible beliefs and values; it emerged
as a foundation for ethical decision making. Principles
were expansive enough to be shared by all rational
individuals, regardless of their background and
individual beliefs. This approach continued into the
1900s and was popularized by two bioethicists,
Beauchamp and Childress (1977; 1994), in the last
quarter of the 20th century. Principles are considered
broad guidelines that provide guidance or direction but
leave substantial room for case-specific judgment.
From principles, one can develop more detailed rules
and policies.
Beauchamp and Childress (1994) proposed four
guiding principles: (1) respect for autonomy, (2)
nonmaleficence, (3) beneficence, and (4) justice.
Autonomy refers to the individual’s freedom from
controlling interferences by others and from
personal limitations that prevent meaningful
choices, such as adequate understanding. Two
conditions are essential for autonomy: liberty,
meaning the independence from controlling
influences, and the individual’s capacity for
intentional action.
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Nonmaleficence asserts an obligation not to inflict
harm intentionally and forms the framework for the
standard of due care to be met by any professional.
Obligations of nonmaleficence are obligations of not
inflicting harm and not imposing risks of harm.
Negligence—a departure from the standard of due
care toward others—includes intentionally imposing
risks that are unreasonable and unintentionally but
carelessly imposing risks.
Beneficence refers to actions performed that
contribute to the welfare of others. Two principles
underlie beneficence: Positive beneficence requires
the provision of benefits, and utility requires that
benefits and drawbacks be balanced. One must
avoid negative beneficence, which occurs when
constraints are placed on activities that, even
though they might not be unjust, could in some
situations cause detriment or harm to others.
Justice refers to fair, equitable, and appropriate
treatment in light of what is due or owed to a
person. Distributive justice refers to fair, equitable,
and appropriate distribution in society determined
by justified norms that structure the terms of social
cooperation.
Beauchamp and Childress also suggest three types of
rules for guiding actions: substantive, authority, and
procedural. (Rules are more restrictive in scope than
principles and are more specific in content.)
Substantive rules are rules of truth telling,
confidentiality, privacy, and fidelity, and those
pertaining to the allocation and rationing of health care,
omitting treatment, physician-assisted suicide, and
informed consent. Authority rules indicate who may
and should perform actions. Procedural rules establish
procedures to be followed.
The principlism advocated by Beauchamp and
Childress has since given way to the antiprinciplism
movement, which emerged in the 21st century with the
expansive technological changes and the tremendous
rise in ethical dilemmas accompanying these changes.
Opponents of principlism include those who claim that
its principles do not represent a theoretical approach
as well as those who claim that its principles are too far
removed from the concrete particularities of everyday
human existence; are too conceptual, intangible, or
abstract; or disregard or do not take into account a
person’s psychological factors, personality, life history,
sexual orientation, or religious, ethnic, and cultural
background. Different approaches to making ethical
decisions are next briefly explored, providing the
reader with an understanding of the varied methods
professionals may use to arrive at an ethical decision.
The casuist approach to ethical decision making grew
out of the call for more concrete methods of examining
ethical dilemmas. Casuistry is a case-based ethical
reasoning method that analyzes the facts of a case in a
sound, logical, and ordered or structured manner. The
facts are compared to decisions arising out of
consensus in previous paradigmatic or model cases.
One casuist proponent, Jonsen (1991), prefers
particular and concrete paradigms and analogies over
the universal and abstract theories of principlism.
The Husted bioethical decision-making model centers
on the healthcare professional’s implicit agreement
with the patient or client (Husted & Husted, 1995). It is
based on six contemporary bioethical standards: (1)
autonomy, (2) freedom, (3) veracity, (4) privacy, (5)
beneficence, and (6) fidelity.
The virtue ethics approach emphasizes the virtuous
character of individuals who make the choices. A
virtue is any characteristic or disposition desired in
others or oneself. It is derived from the Greek word
aretai, meaning “excellence,” and refers to what one
expects of oneself and others. Virtue ethicists
emphasize the ideal situation and attempt to identify
and define ideals. Virtue ethics dates back to Plato and
Socrates. NR360 Informatic Systems In Healthcare. When asked “whether virtue can be taught or
whether virtue can be acquired in some other way,
Socrates answers that if virtue is knowledge, then it
can be taught. Thus, Socrates assumes that whatever
can be known can be taught” (Scott, 2002, para. 9).
According to this view, the cause of any moral
weakness is not a matter of character flaws but rather
a matter of ignorance. In other words, a person acts
immorally because the individual does not know what
is really good for him or her. A person can, for example,
be overpowered by immediate pleasures and forget to
consider the long-term consequences. Plato
emphasized that to lead a moral life and not succumb
to immediate pleasures and gratification, one must
have a moral vision. He identified four cardinal virtues:
(1) wisdom, (2) courage, (3) self-control, and (4)
justice.
Aristotle’s (350 BC) Nicomachean principles also
contribute to virtue ethics. According to this
philosopher, virtues are connected to will and motive
because the intention is what determines if one is or is
not acting virtuously. Ethical considerations, according
to his eudaemonistic principles, address the question,
“What is it to be an excellent person?” For Aristotle,
this ultimately means acting in a temperate manner
according to a rational mean between extreme
possibilities.
Virtue ethics has experienced a recent resurgence in
popularity (Ascension Health, 2007). Two of the most
influential moral and medical authors, Pellegrino and
Thomasma (1993), have maintained that virtue theory
should be related to other theories within a
comprehensive philosophy of the health professions.
They argue that moral events are composed of four
elements (the agent, the act, the circumstances, and
the consequences), and state that a variety of theories
must be interrelated to account for different facets of
moral judgment.
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Care ethics is responsiveness to the needs of others
that dictates providing care, preventing harm, and
maintaining relationships. This viewpoint has been in
existence for some time. Engster (2004) stated that
“Carol Gilligan’s In a Different Voice (1982) established
care ethics as a major new perspective in
contemporary moral and political discourse” (p. 113).
The relationship between care and virtue is complex,
however. Benjamin and Curtis (1992) base their
framework on care ethics; they propose that “critical
reflection and inquiry in ethics involves the complex
interplay of a variety of human faculties, ranging from
empathy and moral imagination on the one hand to
analytic precision and careful reasoning on the other”
(p. 12). Care ethicists are less stringently guided by
rules, but rather focus on the needs of others and the
individual’s responsibility to meet those needs. As
opposed to the aforementioned theories that are
centered on the individual’s rights, an ethic of care
emphasizes the personal part of an interdependent
relationship that affects how decisions are made. In
this theory, the specific situation and context in which
the person is embedded become a part of the decisionmaking process.
The consensus-based approach to bioethics was
proposed by Martin (1999), who claims that American
bioethics harbors a variety of ethical methods that
emphasize different ethical factors, including principles,
circumstances, character, interpersonal needs, and
personal meaning. Each method reflects an important
aspect of ethical experience, adds to the others, and
enriches the ethical imagination. Thus working with
these methods provides the challenge and the
opportunity necessary for the perceptive and shrewd
bioethicist to transform them into something new with
value through the process of building ethical
consensus. Diverse ethical insights can be integrated
to support a particular bioethical decision, and that
decision can be understood as a new, ethical whole.
Applying Ethics to Informatics
With the Knowledge Age has come global closeness,
meaning the ability to reach around the globe
instantaneously through technology. Language barriers
are being broken through technologically based
translators that can enhance interaction and exchange
of data and information. Informatics practitioners are
bridging continents, and international panels,
committees, and organizations are beginning to
establish standards and rules for the implementation of
informatics. This international perspective must be
taken into consideration when informatics dilemmas
are examined from an ethical standpoint; it promises to
influence the development of ethical approaches that
begin to accept that healthcare practitioners are
working within international networks and must
recognize, respect, and regard the diverse political,
social, and human factors within informatics ethics.
The various ethical approaches can be used to help
healthcare professionals make ethical decisions in all
areas of practice. The focus of this text is on
informatics. Informatics theory and practice have
continued to grow at a rapid rate and are infiltrating
every area of professional life. New applications and
ways of performing skills are being developed daily.
Therefore, education in informatics ethics is extremely
important.
Typically, situations are analyzed using past
experience and in collaboration with others. Each
situation warrants its own deliberation and unique
approach, because each individual patient seeking or
receiving care has his or her own preferences, quality
of life, and healthcare needs in a situational milieu
framed by financial, provider, setting, institutional, and
social context issues. Clinicians must take into
consideration all of these factors when making ethical
decisions. NR360 Informatic Systems In Healthcare.
The use of expert systems, decision support tools,
evidence-based practice, and artificial intelligence in
the care of patients creates challenges in terms of who
should use these tools, how they are implemented, and
how they are tempered with clinical judgment. All
clinical situations are not the same, and even though
the result of interacting with these systems and tools is
enhanced information and knowledge, the clinician
must weigh this information in light of each patient’s
unique clinical circumstances, including that
individual’s beliefs and wishes. Patients are demanding
access to quality care and the information necessary to
control their lives. Clinicians need to analyze and
synthesize the parameters of each distinctive situation
using a specific decision-making framework that helps
them make the best decisions. Getting it right the first
time has a tremendous impact on expected patient
outcomes. The focus should remain on patient
outcomes while the informatics tools available are
ethically incorporated.
Facing ethical dilemmas on a daily basis and struggling
with unique client situations may cause many clinicians
to question their own actions and the actions of their
colleagues and patients. One must realize that
colleagues and patients may reach very different
decisions, but that does not mean anyone is wrong.
Instead, all parties reach their ethical decision based
on their own review of the situational facts and
understanding of ethics. As one deals with diversity
among patients, colleagues, and administrators, one
must constantly strive to use ethical imagination to
reach ethically competent decisions.
Balancing the needs of society, his or her employer,
and patients could cause the clinician to face ethical
challenges on an everyday basis. Society expects
judicious use of finite healthcare resources. Employers
have their own policies, standards, and practices that
can sometimes inhibit the practice of the clinician. Each
patient is unique and has life experiences that affect
his or her healthcare perspective, choices, motivation,
and adherence. Combine all of these factors with the
challenges posed by informatics, and it is clear that the
evolving healthcare arena calls for an informaticscompetent, politically active, consumer-oriented,
business-savvy, ethical clinician to rule this everchanging landscape known as health care.
The goal of any ethical system should be that a
rational, justifiable decision is reached. Ethics is always
there to help the practitioner decide what is right.
Indeed, the measure of an adequate ethical system,
theory, or approach is, in part, its ability to be useful in
novel contexts. A comprehensive, robust theory of
ethics should be up to the task of addressing a broad
variety of new applications and challenges at the
intersection of informatics and health care.
The information concerning an ethical dilemma must
be viewed in the context of the dilemma to be useful.
Bioinformatics could gather, manipulate, classify,
analyze, synthesize, retrieve, and maintain databases
related to ethical cases, the effective reasoning applied
to various ethical dilemmas, and the resulting ethical
decisions. This input would certainly be potent—but the
resolution of dilemmas cannot be achieved simply by
examining relevant cases from a database. Instead,
clinicians must assess each situational context and the
patient’s specific situation and needs and make their
ethical decisions based on all of the information they
have at hand.
Ethics is exciting, and competent clinicians need to
know about ethical dilemmas and solutions in their
professions. Ethicists have often been thought of as
experts in the arbitrary, ambiguous, and ungrounded
judgments of other people. They know that they make
the best decisions they can based on the situation and
stakeholders at hand. Just as clinicians try to make the
best healthcare decisions with and for their patients,
ethically driven practitioners must do the same. Each
healthcare provider must critically think through the
situation to arrive at the best decision.
To make ethical decisions about informatics
technologies and patients’ intimate healthcare data and
information, the healthcare provider must be competent
in informatics. To the extent that information technology
is reshaping healthcare practices or promises to
improve patient care, healthcare professionals must be
trained and competent in the use of these tools. This
competency needs to be evaluated through
instruments developed by professional groups or
societies; such assessment will help with consistency
and quality. For the healthcare professional to be an
effective patient advocate, he or she must understand
how information technology affects the patient and the
subsequent delivery of care. Information science and
its effects on health care are both interesting and
important. It follows that information technology and its
ethical, social, and legal implications should be
incorporated into all levels of professional education.
The need for confidentiality was perhaps first
articulated by Hippocrates; thus if anything is different
in today’s environment, it is simply the ways in which
confidentiality can be violated. Perhaps the use of
computers for clinical decision support and data mining
in research will raise new ethical issues. Ethical
dilemmas associated with the integration of informatics
must be examined to provide an ethical framework that
considers all of the stakeholders. Patients’ rights must
be protected in the face of a healthcare provider’s duty
to his or her employer and society at large when
initiating care and assigning finite healthcare
resources. An ethical framework is necessary to help
guide healthcare providers in reference to the ethical
treatment of electronic data and information during all
stages of collection, storage, manipulation, and
dissemination. These new approaches and means
come with their own ethical dilemmas. Often they are
dilemmas not yet faced owing to the cutting-edge
nature of these technologies.
Just as processes and models are used to diagnose
and treat patients in practice, so a model in the
analysis and synthesis of ethical dilemmas or cases
can also be applied. An ethical model for ethical
decision making (Box 5-1) facilitates the ability to
analyze the dilemma and synthesize the information
into a plan of action (McGonigle, 2000). The model
presented here is based on the letters in the word
ethical. Each letter guides and prompts the healthcare
provider to think critically (think and rethink) through
the situation presented. The model is a tool because, in
the final analysis, it allows the nurse objectively to
ascertain the essence of the dilemma and develop a
plan of action. NR360 Informatic Systems In Healthcare.
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