Ethics and Values

Autonomy

When applied to politics or government, autonomy refers to freedom from external control. Similarly in health care, respect for autonomy refers to the commitment to include patients in decisions about all aspects of care as a way of acknowledging and protecting a patient’s independence. For example, when a patient faces surgery, the surgeon has an obligation to review the surgical procedure, including risks and benefits, out of respect for the patient’s autonomy. The consent that patients read and sign before surgery documents this respect for autonomy.

Beneficence

Beneficence refers to taking positive actions to help others. The principle of beneficence is fundamental to the practice of nursing and medicine. The agreement to act with beneficence implies that the best interests of the patient remain more important than self-interest. It implies that nurses practice primarily as a service to others, even in the details of daily work.

Nonmaleficence

Maleficence refers to harm or hurt; thus nonmaleficence is the avoidance of harm or hurt. In health care, ethical practice involves not only the will to do good, but the equal commitment to do no harm. The health care professional tries to balance the risks and benefits of care while striving at the same time to do the least harm possible. A bone marrow transplant procedure may offer a chance at cure; but the process involves periods of suffering, and it may not be possible to guarantee a positive outcome. Decisions about the best course of action can be difficult and full of uncertainty, precisely because nurses agree to avoid harm at the same time as they commit to promoting benefit.

Justice

Justice refers to fairness. The term is most often used in discussions about access to health care resources, including the just distribution of resources. Discussions about health insurance, hospital locations and services, even organ transplants generally refer to issues of justice. The term just culture refers to the promotion of open discussion whenever mistakes occur, or nearly occur, without fear of recrimination. By fostering open discussion about errors, members of the health care team become informed participants, able to design new systems that prevent harm.

Fidelity

Fidelity refers to the agreement to keep promises. As a nurse you keep promises by following through on your actions and interventions. If you assess a patient for pain and offer a plan to manage the pain, the standard of fidelity encourages you to monitor the patient’s response to the plan. Professional behavior includes revision of the plan as necessary to try to keep the promise to reduce pain. Fidelity also refers to the unwillingness to abandon patients even when care becomes controversial or complex.

Advocacy

Advocacy refers to the support of a particular cause. As a nurse you advocate for the health, safety, and rights of patients, including their right to privacy. Your special relationship with patients provides you with knowledge that is specific to your role as a registered nurse and as such provides you the opportunity to make a unique contribution to understanding a patient’s point of view.

Responsibility

The word responsibility refers to a willingness to respect one’s professional obligations and follow through on promises. As a nurse you are responsible for your actions and for the actions of those to whom you delegate tasks. You strive to remain competent to practice so you are able to follow through on your responsibilities reliably.

Accountability

Accountability refers to the ability to answer for one’s actions. You learn to ensure that your professional actions are explainable to your patients and your employer. Health care institutions also exercise accountability by monitoring individual and institutional compliance with national standards established by agencies such as The Joint Commission (TJC) and the ANA. Compliance officers in most health care facilities provide compliance oversight. TJC establishes national guidelines to ensure patient and workplace safety through consistent, effective nursing practices (TJC, 2011). ANA sets national standards for continuing education and curriculum development for nursing schools (ANA, 2011). TJC and ANA promote ethical decision making by requiring health care institutions to create a multidisciplinary forum, or ethics committee, for discussion of ethical issues.

Confidentiality

The concept of confidentiality in health care is widely respected. Federal legislation known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates the protection of patients’ personal health information. The legislation defines the rights and privileges of patients for protection of privacy. It establishes fines for violations (US Department of Health and Human Services, 2011). See Chapter 26 for details on HIPAA regulations governing communication of patient information contained in medical records, both hardcopy and electronic.

Value Formation

Development of values begins in childhood, shaped by experiences within the family unit. Variations in childrearing result in variations in values and behaviors as children grow. The fundamental urge to love and nurture children takes on different expressions within each of the wide variety of cultures in our world.

Schools, governments, religious traditions, and other social institutions play a role in the formation of values, reinforcing or sometimes challenging family values. Over time an individual acquires values by choosing some that the community holds strongly and perhaps discarding or transforming others.

Finally, individual experiences (i.e., the unpredictable twists and turns that occur in life) influence value formation. A person who suffers great loss early in life can grow to value things differently from someone whose life has been free from suffering.

Values Clarification

Ethical dilemmas almost always occur in the presence of conflicting values. To resolve ethical dilemmas one needs to distinguish among value, fact, and opinion. Sometimes people have such strong values that they consider them to be facts, not just opinion. Sometimes people are so passionate about their values that they provoke judgmental attitudes during conflict. Clarifying values—your own, your patients’, your co-workers’—is an important and effective part of ethical discourse. In the process of values clarification, you learn to tolerate differences in a way that often (although not always) becomes the key to the resolution of ethical dilemmas.

Examine the cultural values exercise in Box 22-3. The values in the exercise conflict are in neutral terms so you can appreciate how differing values need not indicate “right” or “wrong.” For example, for some people it is important to remain silent and stoic in the presence of great pain, and for others it is important to talk about it to understand and control it. Identifying values as something separate from facts can help you find tolerance for others, even when differences among you seem worlds apart.

Deontology

A traditional ethical theory, deontology proposes a system of ethics that is perhaps most familiar to health care practitioners. Its foundations come from the work of an eighteenth-century philosopher, Immanuel Kant (1724-1804). Deontology defines actions as right or wrong based on their “right-making characteristics” such as fidelity to promises, truthfulness, and justice (Beauchamp and Childress, 2008). It specifically does not look to consequences of actions to determine right or wrong. Instead it examines a situation for the existence of essential right or wrong. For example, if you try to make a decision about the ethics of a controversial medical procedure, deontology guides you to focus on how the procedure ensures fidelity to the patient, truthfulness, justice, and beneficence. You focus less on the consequences (ethically speaking). If an act is just, respects autonomy, and provides good, it will be right, and it will be ethical according to this philosophy. Deontology depends on a mutual understanding and acceptance of these principles.

Often people in ethical dilemmas have to choose between conflicting principles. For example, application of the principle of respect for autonomy is sometimes confusing when dealing with children. The health care team may recommend a certain course of treatment, but the parent disagrees or even refuses the recommendation. Whose autonomy should receive the respect—the parent’s? Who should speak for the child’s best interest? Communities struggle to decide who ultimately is responsible for the well-being of children. A commitment to respect the “rightness” of autonomy is a guiding principle in deontology, but adherence to the principle alone may not provide clear answers to ethical dilemmas.

Utilitarianism

A utilitarian system of ethics proposes that the value of something is determined by its usefulness. This philosophy is also known as consequentialism because its main emphasis is on the outcome or consequence of action. A third term associated with this philosophy is teleology, from the Greek word telos, meaning “end,” or the study of ends or final causes. John Stuart Mill (1806-1873), a British philosopher, first proposed its philosophical foundations. The greatest good for the greatest number of people is the guiding principle for determining right action in this system. As with deontology, utilitarianism relies on the application of a certain principle, (i.e., measures of “good” and “greatest”) (Beauchamp and Childress, 2008). The difference between utilitarianism and deontology is the focus on outcomes. Utilitarianism measures the effect that an act will have; deontology looks to the presence of principle regardless of outcome.

People have conflicting definitions of “greatest good.” For example, research suggests that education about safe sex practices reduces the spread of human immunodeficiency virus (HIV). Reducing incidence of HIV is good for a great number of people. For some, education about sex is best provided within a family setting rather than in school because it promotes family values. However, for others the greater good is educating the greatest number of people in the most effective way possible; therefore sex education in the public schools would ensure the greatest good. As with deontology, utilitarianism provides guidance, but it does not guarantee agreement.

Feminist Ethics

Feminist ethics critiques conventional ethics such as deontology and utilitarianism. It looks to the nature of relationships to guide participants in making difficult decisions, especially relationships in which power is unequal or in which a point of view has become ignored or invisible (Brody, 2009). Writers with a feminist perspective tend to concentrate more on practical solutions than on theory.

Feminist ethicists propose that the natural human urge to be influenced by relationships is a positive value. Critics of feminist ethics are concerned about the lack of focus on universal principals. Without guidance from universal principals, they argue, solutions depend completely on the situation itself.

Ethics of Care

The ethics of care and feminist ethics are closely related. Both promote a philosophy that focuses on understanding relationships, especially personal narratives.

An early proponent of the ethics of care, Nel Noddings (1984), used the term the one-caring to identify the individual who provides care, and the cared-for to refer to the patient. In adopting this language Noddings hoped to emphasize the role of feelings. Contemporary writers such as Virginia Held (2005) continue to build on Noddings’ foundations by making a case for a focus on the fundamental nature of relationships in understanding ethical issues. Ethics of care may even address issues beyond individual relationships such as ethical concerns about the structures within which individual caring occurs such as health care facilities.

Consensus in Bioethics

Bringing different points of view to agreement and harmony, or consensus, requires skill and patience. Building consensus is essentially an act of discovery, in which “collective wisdom” guides a group to the best possible decision. It encourages respect for unusual points of view while striving for agreement among all participants (Dressler, 2006). As a strategy for solving dilemmas, consensus building promotes respect and agreement rather than a particular philosophy or moral system itself. In the example of the processing of the ethical dilemma described in this chapter, the process is basically one of consensus building.

Processing an Ethical Dilemma

Ethical dilemmas cause distress and controversy for both patients and caregivers. To minimize distress, you learn to process ethical issues carefully and deliberately. The process should promote the free expression of feelings and opinions. However, you do not resolve an ethical dilemma by considering only what people want and feel (Zoloth, 2010).

Resolving an ethical dilemma is similar to the nursing process in its methodical approach to a clinical issue. But it differs from the nursing process in that it requires negotiation of differences of opinion. As Zoloth (2010) suggests, the resolution of conflicting opinions works best when the following elements are part of the process: the presumption of good will on the part of all participants, strict adherence to confidentiality, patient-centered decision making, and the welcome participation of families and primary caregivers.

The process begins with gathering all pertinent information for an assessment and continues with planning, implementation, and evaluation. To distinguish an ethical problem from other kinds of problems, Curtin (2004) proposes that, if the issue is an ethical one, it entails at least one of the following:

Participants begin the process with a clear statement of the ethical problem. Agreement about the nature of the problem facilitates constructive discussion. Next, listing possible courses of action helps the group explore options and identify dissent. As a group you consider and evaluate alternatives with respect for all differences of opinion. Most of the time people in an ethical conflict come to a resolution and implement a plan. Evaluation of the plan follows (Box 22-4).

If the process involves a family conference or changes in the management plan, you document the process in the medical record. Some institutions use a special ethics consultation form to structure documentation. However, if the ethical concern does not directly affect patient care, you may document the discussion in meeting minutes or in a memorandum to those involved in the discussion.

Now that we have established basic vocabulary terms and reviewed a variety of ethics philosophies, let us return to the patient care scenario at the beginning of this chapter to illustrate how methodical processing can help to resolve an ethical dilemma.

You are caring for a patient with a terminal illness. The patient has discussed with you her desire to explore DNR orders. However, she expresses conflicting sentiments to the admitting physician, and you are challenged with how to proceed.

Step 1. Is this situation an ethical dilemma? If the question remains perplexing and the answer will have profound relevance for several areas of human concern, an ethical dilemma exists.

Your situation meets the criteria for an ethical dilemma. The disagreement does not revolve around whether the patient is in a terminally ill state; thus further clinical information will not change the basic question: Should the patient have an opportunity to discuss DNR orders at this time? The question is perplexing. Two professional team members, you and the attending physician, disagree on an assessment of a patient’s readiness to confront difficult issues related to dying. The answer to the question, “Is this patient ready to discuss end of life?” has important human implications. If she is not ready, raising the issues could cause anguish and fear in the patient and her family. If she is ready and the team avoids discussion, she could suffer unnecessarily in silence. If she is very close to death, the lack of a DNR order necessitates the application of cardiopulmonary resuscitation (CPR) in a futile situation. As a nurse you know that CPR can cause pain. If applied when an extension of life is unlikely, it could prolong suffering and reduce dignity. On the other hand, if the patient or her loved ones prefer to ensure that all actions to preserve life are taken, regardless of the outcome, a DNR order would violate the patient’s wishes.

Step 2. Gather as much information as possible that is relevant to the case. Because resolution of dilemmas often comes from unlikely sources, it is helpful to incorporate as much knowledge as possible. Helpful information includes laboratory and test results, the clinical state of the patient in question, and current literature about the diagnosis or condition of the patient. A patient’s religious, cultural, and family situations are part of the assessment.

Since the dilemma exists because two professionals disagree about a patient’s state of mind, it is helpful to reassess the patient. An independent assessment could help resolve differences of opinion. Family members or significant others in the patient’s life often hold important clues to a patient’s state of mind.

Step 3. Examine and determine your values about the issues. Part of the goal is to accurately identify your own opinion. An equally critical goal is to form respect for others’ opinions.

Reflect on your values. You think that this patient wants a DNR order in place. But does this opinion accurately represent the patient’s wishes? Let’s say that your religious beliefs would allow you to obtain DNR status if you were in the patient’s condition. After talking with the patient, you learn that her religion discourages acts that diminish life in any way. You realize that she may have come to view a DNR order as “giving up” or “acting like God.” In addition, you understand that the attending physician has not had time to know this patient well. You continue to believe that the patient is capable of a discussion, in spite of her statements to the physician. In fact, you believe that she will benefit from a discussion, regardless of the final decision. Perhaps the combination of an unfamiliar caretaker and declining physical health has silenced her, even though her fears and concerns persist.

Step 4. Verbalize the problem. By agreeing to a statement of the problem, the group is able to conduct a focused discussion.

Is a DNR order right or wrong thing for this patient? Is she ready to discuss the options?

Step 5. Consider possible courses of action. What options are possible in this situation?

Do you initiate a discussion with the patient independent of the physician? Is this outside of your professional domain, and is it in the patient’s best interest for you to facilitate a DNR order from another physician? What if your assessment of the patient is incorrect? Do you contribute to the dignity or the distress of the patient? The answers to these questions can be elusive because they depend on an understanding of patient feelings and values that are not necessarily obvious. Even if you cannot write a DNR order legally, it does not relieve you of troubling questions because the ability to influence a physician’s or patient’s decision regarding DNR remains.

Step 6. Negotiate the outcome. Negotiations happen informally at the bedside or in a conference room. Sometimes a formal ethics meeting is necessary. Wherever negotiations occur, the nurse has an obligation to articulate a personal point of view.

If an ethics committee meeting occurs, the discussion usually involves participants from several disciplines. A facilitator or chairperson ensures that the group examines all points of view and identifies all relevant issues. In the best circumstances participants discover a course of action that meets criteria for consensus, or acceptance by all. However, occasionally they leave the discussion disappointed or even opposed to the decision. But in a successful discussion all members will have agreed on an action.

The principles involved during the discussion include beneficence and nonmaleficence: Which plan would provide the most good for this patient, a DNR order or no order? A separate question addresses the patient’s point of view and a respect for autonomy: Would a discussion with the patient promote well-being or anguish? The commitment to respect a patient’s autonomy reveals that a troublesome question remains: Does the patient want something different from what she is expressing?

With several members of the health care team present, the discussion proceeds. You present your point of view. You continue to sense that the patient is ready to discuss DNR orders. But you also respect the attending physician and his perception that the patient is reluctant to talk freely about it. In the end the team proposes the following: a formal meeting with the patient in which you, the attending physician, and a respected family member are present. You support this proposal because you believe that it maximizes comfort from the patient’s network of friends and family. In addition, you recognize that in a trusting environment the patient is most likely to express herself freely. You suggest that, rather than asking if the patient wants a DNR order, perhaps the team could wait for her to initiate the discussion. In this way the team would be sure of her consent and willingness to address the difficult questions about dying.

Step 7. Evaluate the action.

At the meeting the patient brings up the DNR order. She expresses relief at the chance to explore her options and feelings. The physician clarifies pain management issues that she broaches. She wants to discuss a DNR order but requests a visit from her priest before making a final decision.

Institutional Resources

Health care institutions establish ethics committees to process ethical dilemmas. Ethics committees are usually multidisciplinary and serve several purposes: education, policy recommendation, and case consultation. Any person involved in an ethical dilemma, including nurses, physicians, health care providers, patients, and family members, can request access to an ethics committee.

You also process ethical issues in settings other than a committee. Nurses provide insight about ethical problems at family conferences, staff meetings, or even in one-on-one meetings.

Many ethical problems begin when people feel misled or are not aware of their options and do not know when to speak up about their concerns. You address such concerns in a variety of constructive settings. Ethics committees serve to complement relationships within the workplace and the community and offer a valuable resource for strengthening these relationships (Box 22-5).

Quality of Life

Quality of life represents something deeply personal. Health care researchers work to develop quality-of-life measures to define scientifically the value and benefits of certain medical interventions. Statistical analyses help scientists apply the measures in research and other settings (Walters, 2009). These measures take into account the age of the patient, the patient’s ability to live independently, his or her ability to contribute to society in a gainful way, and other nuanced measures of quality. The question of quality of life is central to discussions about futile care, cancer therapy, health care provider–assisted suicide, and DNR discussions.

The population of disabled persons in the United States and elsewhere has reshaped the discussion about quality of life. The national movement to respect the abilities of the “disabled” has raised the visibility of quality-of-life issues and forced a reconsideration of the definition of quality. For example, many school districts no longer separate physically or mentally challenged children but rather integrate them into mainstream classrooms. Public places such as restaurants and buses are accessible to people who use wheelchairs. Antidiscrimination laws enhance the economic security of people with physical, mental, or emotional challenges. These changes have increased the integration of disabled persons into general society. The changes remind society, including health care workers, that definitions of quality are deeply based in individual experience.

Genetic Screening

Genetic testing can alert a patient to a condition that may not yet be evident but that is certain to develop in the future. What are the risks and benefits to individuals and to society of learning about the presence of a disease that has not yet caused symptoms or for which a cure is not yet available? The presence of Huntington’s disease, an incurable disease for now, is detectable by genetic testing. Huntington’s disease is a degenerative neurological disease that affects cognitive, emotional, and physical function. Symptoms usually do not appear until the third or fourth decade of life. If a parent or grandparent has the disease, offspring are at risk for developing it (National Institute of Neurological Disorders and Stroke, 2010). Patients may be eager to learn if they will develop the disease so they are able to make decisions about childbearing, career, and retirement planning. Others are reluctant to face the knowledge that they have the disease before symptoms begin, unwilling to compromise healthy years with anxieties about pending emotional and intellectual losses (Wexler, 2010).

Care at the End of Life

Predictions about health outcomes are not always accurate. Even when they are, opinions about the value or worth of the outcome differ. For example, patients at risk for breast cancer occasionally request a mastectomy before any symptoms of breast disease have appeared, fearful of a family history and thinking that it will prevent future suffering. Physicians may be understandably reluctant to provide this intervention, based on knowledge of risk factors and their commitment to “do no harm.” On the other hand, a physician might recommend that a patient undergo a liver transplantation for end-stage liver disease even though the likelihood of a cure is uncertain. The patient may hold the opinion that the transplant is pointless: unlikely to produce benefit that justifies the suffering he or she anticipates. Agreement on what is best is often elusive.

The term futile refers to something that is hopeless or serves no useful purpose. In health care discussions the term refers to interventions unlikely to produce benefit for a patient. The concept is slippery when applied to clinical situations.

If a patient is dying, in a condition with little or no hope of recovery, almost any intervention beyond symptom management and comfort measures is seen as futile. In this situation an agreement to label an intervention as futile can help providers, families, and patients turn to palliative care measures as a more constructive approach to the situation (see Chapter 36).

When an aging patient is at the end of life, issues may be complicated by his or her ability to make competent decisions because of conditions such as dementia or stroke. How and when to respect the wishes of older patients whose cognitive capacities are in doubt or dispute can complicate clinical decisions and necessitate ethical discourse (Box 22-6).

Access to Care

The number of uninsured in the United States grew from 39 million people in 2000 to more than 46.3 million people by 2008, over 15% of the total population (US Census Bureau, 2009). Many of the uninsured are women or children. The Kaiser Family Foundation reports that young adults ages 19 to 29 have the highest uninsured rate of any age-group in the United States and represent 30% of the overall uninsured population (Schwartz and Schwartz, 2010). Although two thirds of the uninsured are poor, nearly 80% come from working families (Holahan, Cook, and Dubay, 2007). Access to care and health care reform may seem distantly related to your daily job or a specific patient care assignment. But as a nurse you will certainly deal with ethical issues related to access to care. You may care for a patient about to be discharged from the hospital when you find that he or she cannot afford to fill a prescription. Do you advocate for a delay in discharge? Do you have time to find financial resources to subsidize the prescription costs? Your involvement with issues such as these and others requires a dedication to your professional ethics, a personal commitment to continuing education, and continuing engagement.

• • •

The courage and intelligence to act as both an advocate for patients and a professional member of the health care community come from a committed effort to learn and understand ethical principles. As a professional nurse you provide a unique point of view regarding patients, the systems that support patients, and the institutions that make up the health care system. You have a duty and a privilege to articulate that point of view. Learning the language of ethical discourse is a part of the skill necessary to exercise this privilege. Review and consideration of various ethical principles helps you form personal points of view, a necessary factor in the negotiation of difficult ethical situations.

• Ethics is the study of conduct and character. It is concerned with determining what is good or valuable for individuals and society at large.

• The ANA code of ethics provides a foundation for professional nursing.

• Professional nursing promotes accountability, responsibility, advocacy, and confidentiality.

• Standards of ethics in health care include autonomy, beneficence, nonmaleficence, justice, and fidelity.

• The process of values clarification helps you to explore values and feelings and decide how to act on personal beliefs and respect values of others, even if they differ from yours.

• Ethical problems arise in the presence of differences in values, changing professional roles, technological advances, and social issues that influence quality of life.

• A process for resolving ethical dilemmas that respects differences of opinions and all participants equally helps health care providers resolve conflict about right actions.

• A nurse’s point of view offers a unique voice in the resolution of ethical dilemmas.

Clinical Application Questions

Review Questions

American Nurses Association (ANA). Education and competence. 2011, http://www.nursingworld.org/. [Accessed January 20, 2011].

Beauchamp, T, Childress, J. Principles of biomedical ethics, ed 4. New York: Oxford University Press; 2008.

Brody, H. Future of bioethics. New York: Oxford University Press; 2009.

Burke, MM, Laramie, JA. Primary care of the older adult: a multidisciplinary approach. St Louis: Mosby; 2003.

Curtin, L. Ethics in management: the ethical handling of ethical issues. J Clin Syst Manage. 2004;6(4):14. [2004].

Dressler, L. Consensus through conversation: how to achieve high-commitment decisions. San Francisco: Barrett-Koehler; 2006.

Held, V. The ethics of care. Oxford: Oxford University Press; 2005.

Holahan, J, Cook, A, Dubay, L, Characteristics of the uninsured: who is eligible for public coverage and who needs help affording coverage. Menlo Park, CA: Henry J. Kaiser Family Foundation; 2007. http://www.kff.org/uninsured/upload/7613.pdf

National Institute of Neurological Disorders and Stroke. Huntington’s disease information page. http://www.ninds.nih.gov/disorders/huntington/huntington.htm, 2010.

Noddings, N. Caring: a feminist approach to ethics and moral education. Berkeley: University of California Press; 1984.

Pottinger, A, et al. The end of life. In: Srivaastava RH, ed. Guide to clinical cultural competence. Toronto: Elsevier, 2007.

Schwartz, K, Schwartz, T, How will health reform impact young adults?. Menlo Park, CA: Henry J. Kaiser Family Foundation; May 2010. http://www.kff.org/healthreform/upload/7785-03.pdf

The Joint Commission (TJC). Joint Commission requirements and 2011 summary of national patient safety goals. http://www.jointcommission.org/standards_information/npsgs.aspx, 2011.

US Census Bureau. Income, poverty, and health insurance coverage in the United States. http://www.census.gov/prod/2010pubs/p60-238.pdf, 2009.

US Department of Health and Human Services, Office for Civil Rights. HIPAA medical privacy, national standards to protect the privacy of personal health information. http://www.hhs.gov/ocr/hipaa/, 2011.

Walters, SJ. Quality of life outcomes in clinical trials and health care evaluation. New Jersey: John Wiley and Sons; 2009.

Wexler, A. The woman who walked into the sea: Huntington’s and the making of a genetic disease. New Haven: Yale University Press; 2010.

Zoloth, L. Learning a practice of uncertainty: clinical ethics and the nurse. In Cowen PS, Moorhead S, eds.: Current issues in nursing, ed 7, St Louis: Mosby, 2010.

Crawley, LM, et al. Strategies for culturally effective end-of-life care. Ann Intern Med. 2002;136:673.

Hamric, AB, Blackhall, LB. Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate. Crit Care Med. 2007;35(2):422.

Ulrich, CM, Hamric, AB, Grady, C. Moral distress: a growing problem in the health professions? Hastings Cent Rep. 2010;40(1):20.

Volker, DL. Control and end-of-life care: does ethnicity matter? Am J Hosp Palliat Care. 2005;22(6):442.