Advanced practice registered nurses (APRNs) are active in a variety of clinical, educational, and executive

roles, with varying degrees of involvement in and influence over clinical practice. As part of their
professional role, APRNs must be able to recognize ethical conflicts and serve as mediators or resources
for patients, families, or other nurses who are struggling with ethical dilemmas. The new doctorate of
nursing practice (DNP) requirement will expand the knowledge required and the role of APRNs in a
variety of settings. Ulrich and colleagues (2006) found that 25% of the nurse practitioner (NP) and
physician assistant (PA) respondents they studied felt isolated in making ethical decisions, and 68% of
them expressed the need for more ethics training. Understanding the application of ethical constructs
and theories is essential for APRNs as they address complex health issues and manage ethical conflicts in
research and business arenas (Peirce & Smith, 2008).

APRNs are confronted with a variety of everyday ethical conflicts, including:

1. Patient or family conflicts when the prognosis or goals of care are unclear (Dubler, 2011; Laabs, 2005;
Ulrich et al., 2010; Wiegand, 2003)

2. Family conflicts when surrogates are not honoring the patient's advance directives or when there is
uncertainty over the aggressiveness of care in pediatric or terminally ill patients who lack decisional
capacity (Dubler, 2011; Laabs, 2005; Peirce & Smith, 2008; Ulrich et al, 2010; Volker, Kahn, & Penticuff,
2004)

3. Clients whose care is compromised because of inadequate funding by insurers or inadequate personal
or public resources (Baum, Gollust, Goold, & Jacobson, 2007; Browne & Tarlier, 2008; Laabs, 2005; Ulrich
et al., 2006)

4. Concerns about privacy and confidentiality of information in the era of human genomics and
protected health information in the electronic medical record (Badzek, Henaghan, Turner, & Monsen,
2013; Demiris, Oliver, & Courtney, 2006; Peirce & Smith, 2008; Ulrich et al, 2010)

5. Conflicts between insurer/payer system guidelines and the perceived most appropriate care (Laabs,
2005; Ulrich et al, 2006; Ulrich & Soeken, 2005)
6. Unethical practices of health care colleagues or demands by employers for coding or billing practices
that may be questionable or fraudulent (Peirce & Smith, 2008; Laabs, 2005; Hannigan, 2006: Ulrich et al.,
2010)

7. Undue influence or conflict of interest in prescribing because of pharmaceutical promotions or use of

pharmaceutical samples (Crigger, 2005; Erlen, 2008)

8. Struggles with pain management and opiate prescribing practices for patients in chronic pain
(Fontana, 2008)

Research exploring nursing ethics for APRNs has also addressed areas such as respect for human dignity
(Kalb & O'Connor-Von, 2007; Ulrich et al., 2010) and the ethical problems encountered by APRNs related
to client care and organizational-industrial issues (Hannigan, 2006; Laabs, 2005, 2007; Ulrich & Hamric,
2008; Ulrich & Soeken, 2005). This chapter reviews basic ethics definitions, discusses keys to application
of ethical guidelines for APRN challenges, and briefly defines and critiques the current ethical decisional
frameworks.

ETHICAL CONCEPTS AND DEFINITIONS

The term ethics is used broadly to understand and examine the moral life, and the norms, social
customs, and rules that define society's conceptions of right and wrong. Ethical theories organize
concepts or principles into a framework that can be used to approach ethical conflicts. Consequentialist
theories identify an action as right or wrong based on the outcome or consequences of that action
(Beauchamp & Childress, 2009). The ends (or consequences, if they are good consequences) justify the
means (or the action taken). The action considered morally right is the action that produces the best
overall result. Utilitarianism, perhaps the most well known of the consequentialist theories, identifies
the principle of utility as the fundamental and only principle of ethics (Beauchamp & Childress, 2009).
Nurses who follow this theory would take the action that produces the greatest good for the greatest
number. For example, APRNs who embrace this theory might work to shape public funding to address
preventive measures or access to basic health care issues for larger populations rather than high-cost
interventions for individuals (Baum, Gollust, Goold, & Jacobson, 2007; Browne & Tarlier, 2008).
Deontologic theories differ widely from consequentialist theories. These theories, based on the works of
Immanuel Kant, identify actions as morally right or wrong in relation to underlying moral principles

(Frankena, 1988). Kant requires that all actions meet the Categorical Imperative: One ought never to act
except in such a way that one can also will that action to become a universal law (Beauchamp &
Childress, 2009; Frankena, 1988). In other words, actions must be reasoned through to determine
whether we would want all others to take that same action in all cases of that kind. Kantian ethics
require the test of universalizability in all ethical decisions. For example, an APRN may believe that lying
to a patient would be wrong in every case (universalizable veracity). The APRN would be morally
conflicted when a family requests that he or she hide the truth from the patient because of the family
concern for that patient's emotional status.

The application of bioethical theories to clinical situations originated when acute care medical
technology advances made it possible to preserve life without consideration to the quality of the life
preserved (Dierckx de Casterle, Roelens, & Gastmans, 1998; Dubler, 2011). Bio-ethicists implemented
ethical theories with a principlist approach as a way to examine ethical conflicts. This rule-based
deontologic approach to ethical problem solving uses the specific bioethical principles of autonomy,
beneficence, nonmaleficence, justice, and rules of veracity, confidentiality, and fidelity (Beauchamp &
Childress, 2009). Bioethicists encourage specific decisional strategies to apply this principlist theory to
clinical situations (Fiester, 2007). APRNs soon discover that ethical principles can conflict and compete
and become the basis for ethical dilemmas in clinical situations. For example, a client may refuse to
follow up by getting a necessary diagnostic test (autonomy) even though obtaining an accurate diagnosis
and appropriate treatment for a recurring problem may benefit the client's health (beneficence) (Dubler,
2011; Fiester, 2007).

There are other ethical theories that may be relevant and helpful guides to health care practitioners.
Virtue ethics offers a framework that provides a warmer interpersonal view of ethical decisions
compared with the calculated reasoning that Kantian principles require. Virtue ethics examines the
character traits that affect a person's judgment and actions and dispose that person to act in accordance
with professional guidelines (Beauchamp & Childress, 2009; Gillon, 2003). The American Nurses
Association (ANA) Code of Ethics (ANA, 2015) is a good example of incorporating virtue ethics into the
ethical and legal obligations of the nursing profession (Exhibit 12.1). Respectfulness and integrity are
identified in this code and have been examined as an important part of ethics education for APRNs (Kalb
& O'Connor-Von, 2007; Peirce & Smith, 2008).
Beauchamp and Childress (2009) refer to virtues of compassion, discernment, trustworthiness,
faithfulness, and integrity as character traits that would produce correct actions in health professionals.
Laabs (2007) describes a theory of maintaining moral integrity in the face of moral conflict as the key
process that NPs use to manage the ethical issues encountered in primary care practices.

EXHIBIT 12.1 ANA Code of Ethics

1. The nurse practices with compassion and respect for the inherent dignity, worth, and unique of
attributes of every person.

2. The nurse's primary commitment is to the patient, whether an individual, family, group, or
community.

3. The nurse promotes, advocates for, and protects rights, the health, and safety of the patient.

4. The nurse has the authority, accountability, and responsibility for nursing practice; makes decisions;
and takes action consistent with the obligation to promote health and to provide optimal care.

5. The nurse owes the same duties to self as to others, including the responsibility to promote health
and safety, preserve wholeness of character and integrity, maintain competence, and continue personal
and professional growth.

6. The nurse, through individual and collective effort, establishes, maintains, and improves the ethical
environment of work setting and conditions of employment that are conducive to safe, quality health
care.

7. The nurse, in roles and settings advances the profession through research and scholarly inquiry,
professional standards development, and the generation of both nursing and health policy.
8. The nurse collaborates with other health professionals and the public to protect human rights,
promote health diplomacy, and reduce health disparities.

9. The profession of nursing, collectively through its professional organizations, must articulate nursing
values, maintain integrity of the profession, and integrate principles of social justice into nursing and
health policy.

Source: American Nurses Association (ANA; 2015).