Table 2 Presence and Conflict of Moral Perspectives and Moral Categories of Justice and Care
Case No | Scene | Moral conflict | Option | Justice perspective | Care perspective |
|---|---|---|---|---|---|
1. Conflict between the justice and care moral categories | |||||
C1 | A physician decided to hospitalize an elderly patient who had refused to be hospitalized at the request of the family. | Whether to oppose physicians’ decision to hospitalize patients according to family’s request | Oppose | (Welfare of Others) Hospitalization is stressful for the patient | |
Do not oppose | (Roles) Follow the direction of the physician who has the authority to decide the hospitalization of the patient (Obligation and commitments) Fulfill the obligation to act under the direction of the physician in the hospital organization | ||||
C2 | During surgery, the work hours of the scrub nurse were coming to an end. | Whether to ask another staff member to take over the task of delivering surgical instruments | Ask | (Rules) Observe the rules of the ward that a person does not work overtime (Obligation and commitments) Do not disrupt organization control | |
Do not ask | (Welfare of Others) Avoid the risk to the patient due to the change of surgical instrument delivery role | ||||
C3 | After cataract surgery in a hepatitis C patient, the patient’s head was contaminated with postoperative drainage. | Whether to use gloves to wipe off postoperative drainage on the patient’s head | Use gloves | (Rules) Act according to infection prevention measures | |
Do not use gloves | (Welfare of Others) Immediately wiping the effluent makes the patient comfortable | ||||
C4 | Because the patient died after ambulance transport, postmortem care for a deceased patient had to be provided. | Whether to perform the postmortem care on a dead patient with his family | Perform with family | (Welfare of Others) Bereaved family can organize their feelings (Care of self) Act in line with belief in building a trusted relationship with patients | |
Do not perform with family | (Rules) Prioritize other duties | ||||
2. Conflict between combinations of justice and care moral categories | |||||
C5 | An elderly patient with an ileus tube had been physically restrained | Whether to continue physical restraint to prevent extubating of the ileus tube | Continue | (Rules) Carry out other duties | (Welfare of Others) Prevent physical pain caused by removal of the ileus tube |
Do not continue | (Rights) Speak for the patient’s desire to remove the restraint band (Rights) Protect the human rights of patients (Societal concerns) Put yourself in patient’s shoes | (Care of self) Dispel feeling of remorse for not being able to comfort the patient (Not hurting) Protect patient dignity | |||
C6 | An elderly terminally ill patient became more restless every night. | Whether to suggest increased sedation for the terminally ill patient to physicians | Suggest | (Rules) Prioritize other tasks over dealing with the restless patient | (Welfare of Others) Weak sedative effects make patients more restless |
Do not suggest | (Rights) Respect the patient’s right to self-determination about receiving sedation (Societal concerns) Put yourself in patient’s shoes | (Welfare of Others) The patient can live comfortably for the rest of their lives | |||
C7 | A terminally ill patient with dysphagia wanted oral intake, but his family was against oral intake. | Whether terminally ill patients at risk of aspiration should be given oral intake | Take orally | (Rights) Respect the patient’s wishes for oral intake (Societal concerns) Put yourself in patient’s shoes | (Welfare of Others) Relieve patient’s thirst and hunger |
Do not take orally | (Roles) Physician’s expert opinion is required to determine oral intake permission | (Appreciation of differences) Understanding the family’s wishes for the patient’s survival | |||
C8 | Chest compressions continued for a patient unlikely to be resuscitated until the family arrived. | Whether to oppose the implementation of slow codes by physicians and senior nurses | Oppose | (Rules) Treat the patient’s corpse with care | (Welfare of Others) Stopping cardiopulmonary resuscitation in dead patients is best |
Do not oppose | (Roles) Follow the judgment of physicians and senior nurses about slow code continuation | (Appreciation of differences) Decisions made by physicians and senior nurses are for the sake of the family | |||
C9 | One of the two patients in charge of an intensive care unit nurse died. | Whether to see off a deceased patient in charge | See off | (Roles) Seeing off is the job of the healthcare provider (Rules) Follow the custom of seeing off a deceased patient experienced at a previous workplace | (Welfare of others) Bereaved families need emotional support (Attachment and connection) I want to snuggle patients slowly after they die |
Do not see off | (Roles) Save the life of another patient with a turn for the worse (Rules) Follow the absolute instructions of the team leader on the shift about the lifesaving of other patients | (Appreciation of differences) Understand the burden on the colleagues who represent critically ill patients | |||
3. Conflict between the combination of justice and care moral categories and justice categories | |||||
C10 | A patient who vomited blood at night was raced to hospital, and the patient needed a blood transfusion | Whether to voluntarily obtain consent for blood transfusion from the patient’s family without a physician’s order | Obtain consent | (Rules) Follow the implied rule of obtaining consent for blood transfusion without a physician’s order | (Welfare of others) Provide beneficial care to patients and families |
Do not obtain consent | (Rules) Obtain consent for blood transfusion under the physician’s order (Legal issues) Exceeding the scope of work stipulated by law is subject to disciplinary action | ||||
C11 | An elderly patient who had refused surgery was rushed to hospital with decreased consciousness and required surgery. | Whether to accept the surrogate decision for consent to surgery by family members | Accept | (Roles) Provide life-saving medical care to patients | (Welfare of others) Make decisions your family won’t regret (Appreciation of differences) Understand the family’s wishes for the patient’s survival |
Do not accept | (Rights) Respect the patient’s right to self-determination according to advance directives | ||||
C12 | A terminally ill patient who said “Don’t resuscitate” was complaining of suffering. | Whether to suggest to the physician to increase the patient’s sedation | Suggest | (Rights) Represent the patient’s distress (Societal concerns) Put yourself in patient’s shoes | (Not hurting) Relieve patient distress with sedation (Care of self) Dispel feeling of remorse for not being able to fulfill the patient’s wishes |
Do not suggest | (Roles) Treatment decisions are a physician’s role | ||||
C13 | While changing a patient’s diaper with a nursing aide, one patient’s sheets were soiled with feces. | Whether to change sheets with feces on them | Change | (Roles) Maintaining the environment and preventing infection by changing sheets (Obligation and commitments) Set an example as a leader for other professions (Societal concerns) Put yourself in patient’s shoes | (Welfare of others) Patients can live comfortably (Care of self) Make decisions with confidence as a professional |
Do not change | (Rules) Continue changing diapers according to ward routine | ||||
C14 | It was decided that surveillance cameras were to be installed in all rooms of the psychiatric ward based on the senior nurse’s opinion. | Whether to require that senior nurses obtain patient consent for the installation of surveillance cameras | Claim | (Rights) Should explain the camera to the patient (Societal concerns) Put yourself in patient’s shoes | (Not hurting) Surveillance is psychologically distressing for patients (Care of self) Dispel feeling of powerlessness not being able to say the right thing |
Do not claim | (Rules) Someone like the leader of the organization who is not the nursing manager decides things. | ||||
4. Conflict between combinations of justice and care moral categories and care categories | |||||
C15 | A patient who had just given birth was admitted for hospitalization for medical treatment and protection | Whether to continue mother-infant separation for the mentally disordered patient immediately after childbirth | Continue | (Welfare of others) The patient is mentally stabilized by receiving drug therapy | |
Do not continue | (Rights) Respect the patient’s right to self-determination | (Not hurting) Relieves emotional distress caused by mother-infant separation (Care of self) Dispel the feeling of helplessness of not being able to let the patient see the child (Attachment and connection) Sympathize with the patient’s distress | |||
C16 | A patient on ventilator was physically restrained because they were more likely to self-extubate. | Whether physical restraint to prevent extubation of the tracheal tube should be continued | Continue | (Rules) Carry out other duties | (Welfare of others) Not self-extubating helps patients get better |
Do not continue | (Welfare of others) Attendant for family is a heavy burden (Care of self) Dispel self-guilt to using physical restraints (Not hurting) Decrease psychological distress caused by physical restraint | ||||
C17 | Parents of a pediatric patient with half a year to live had considered ventilator use. | Whether to advise parents of the pediatric patient not to use a ventilator | Advice | (Welfare of others) Cherish the time the pediatric patient lives (Appreciation of differences) Understand the feelings of parents who wish their children to survive | |
Do not advice | (Rights) Respect the right of children to be free from suffering | (Not hurting) Avoid suffering from endotracheal intubation | |||
C18 | A terminally ill thyroid cancer patient had not been informed of prognosis. | Whether to give information about the prognosis to the patient | Give | (Welfare of others) The patient spends the rest of their lives meaningfully | |
Do not give | (Roles) Nurses have no authority over patient life expectancy | (Appreciation of differences) Understand physicians’ concerns about patients’ fear of death | |||
C19 | A patient with a pressure ulcer on the heel had been instructed to wear a foot pump. | Whether to follow the physician’s orders about wearing a foot pump | Follow | (Roles) Unable to arbitrarily stop the treatment order of the attending physician | (Appreciation of differences) Understand the unpleasant feelings of the attending physician who be objected to the treatment order |
Do not follow | (Welfare of others) Avoid worsening the patient’s pressure ulcer | ||||
C20 | Some colleagues had not been changing diapers or removing phlegm by suction from elderly patients. | Whether to advice the colleagues to change the patient’s diaper changing or removal of phlegm by suction | Advice | (Roles) Medical personnel should work as professionals (Societal concerns) Put yourself in patient’s shoes | (Welfare of others) Deal with the patient if they are in trouble |
Do not advice | (Appreciation of differences) Understand the circumstances of colleagues who do not perform their duties | ||||
C21 | Colleagues objected to administering sedatives to a pulmonary infarction patient who was restless every night. | Whether to administer the patient a sedative against the opinion of colleagues | Administer | (Appreciation of differences) Other inpatients are not disturbed | |
Do not administer | (Rules) Follow a routine that delays the timing of following sedation instructions | (Welfare of others) Physician’s order for sedation is inappropriate for the patient’s restlessness (Appreciation of differences) Understand colleagues’ suggestions for alternatives to sedation | |||
5. Conflict between justice categories | |||||
C22 | The attending physician explained to the patient’s family that the cause of the patient’s death was not his or her fault. | Whether to refute the attending physician, who explains to the patient’s family that they are not at their own fault | Refute | (Roles) It is necessary to explain to the family that it was possible to predict and prevent death from suffocation in the patient. (Legal issues) We should be justly judged by fact-checking | |
Do not refute | (Rules) The attending physician explain to the family (Obligation and commitments) Ward manager’s duty is to report the facts to the attending physician. | ||||
C23 | A schizophrenic patient with overgrown hair could not get a haircut because he did not have the money for a haircut. | Whether the nurse without a beautician license should cut the patient’s hair | Cut the hair | (Rights) Guaranteeing the minimum standard of living as a human being for patients (Roles) I learned that body cleanliness is a job that takes the initiative for patients. | |
Do not cut the hair | (Rules) I don’t want to be punished, so I follow the hospital’s rule of not cutting patients’ hair. (Obligation and commitments) Act in accordance with the duties of the hospital organization | ||||
C24 | A physician had obtained consent for cataract surgery from an elderly patient with poor understanding. | Whether to suggest surrogate decisions for the patient’s family to the physician | Suggest | (Rights) Patient may lack judgment ability (Societal concerns) Put yourself in patient’s shoes | |
Do not suggest | (Roles) Physician has obtained patient consent for surgery | ||||
6. Conflict between care categories | |||||
C25 | A Parkinson’s patient had difficulty walking alone. | Whether to follow the physician’s orders for gait training | Follow | (Welfare of others) Gait training improves activity of daily living in patients (Appreciation of differences) Physician’s orders are based on extensive experience | |
Do not follow | (Welfare of others) Prevent patient falls | ||||
7. No conflict with the combination of justice and care moral category | |||||
C26 | A physician did not examine the elderly patient who was vomiting after hydrocephalus surgery. | Whether to request the physician to examine vomiting patients | Request | (Roles) I need to tell the physician my views about the patient’s examination and treatment (Societal concerns) Put yourself in patient’s shoes | (Welfare of others) The patient’s pain is gone, and the patient’s life is saved (Welfare of others) Patient can return to normal life (Care of self) Dispel the feeling of helplessness in not being able to say the right thing |
Do not request | |||||
C27 | A nurse reported a lung murmur in a leukemia patient to the attending physician, but he did not examine the patient. | Whether to request the patient be examined by the attending physician | Request | (Roles) Don’t overlook the patient’s life-threatening issues | (Welfare of others) Early detection and early treatment benefit the patient |
Do not request | |||||
8. No conflict with the care category | |||||
C28 | A terminally ill patient with bladder cancer demanded nursing care only from a nurse-in-charge. | Accept | |||
Do not accept | (Welfare of others) Patient maintains relationships with other staff (Appreciation of differences) Incorporate staff input for the patient’s benefit | ||||
C29 | A pediatric patient’s mother overly interfered with medical procedures performed by nurses. | Whether to respond to the pediatric patient’s mother’s excessive interference | Respond | ||
Do not respond | (Care of self) Take pride in being a professional (Care of self) I should correct the difference in values with the patient’s mother | ||||