Ethical Considerations in Public Health Nursing

Public health nurses (PHNs) will likely encounter ethical dilemmas throughout their practice. The autonomous nature of public health nursing increases the likelihood that decisions may have to be made that are not clearly objective but contain an element of ethical or moral decision-making. The public health nurse adheres to the American Nurses Association (ANA) Code of Ethics (ANA, 2015). In addition, the Scope and Standards of Practice for Public Health Nursing include competencies specific to Public Health Nursing (American Nurses Association, 2013).

The MORAL model of ethical decision-making

One model for ethical decision-making is the MORAL Model (Krueger, 2008):

• Massage the dilemma
• Outline the options
• Review criteria and resolve
• Affirm position and act
• Look back

Massage the dilemma

• Collect data that identifies the dilemma.
  • Recognize that most problems have more than one component.
  • Identify the facts relevant to the ethical decision.
  • Recognize the cultural, economic, and political contextual factors that are present.
  • Identify the laws, professional ethical codes, and government regulations that impact one's choices.
• Identify who is responsible for making the decision (i.e., whose decision is it to make?).
  • Consider who has important stakes in the decision. Consider the opinions of the major players as well as their value systems.
  • Consider all claimants potentially affected by the decision, in both the majority and the minority. Try to see from the other's perspective.

Outline the options

• Clarify the options available and the consequences of each potential action. This step is used to understand better the options rather than make a final decision.
• Include at least three options in the listing. (It has been noted there are always at least two options, and these two often represent the extremes.)

Review criteria and resolve

• Determine the best/worst case scenarios of choosing each alternative.
• Evaluate from the various moral perspectives of beneficence, autonomy, and justice:
  • Which option will produce the most good and do the least harm (beneficence)?
  • Which option respects the rights and dignity of all stakeholders (autonomy)?
  • Which option promotes the common good (justice)?
• Answer the questions honestly while considering all sides of the issue. Do any rules or principles (legal, professional, organizational, other) automatically invalidate a particular alternative?
• List options in a graph format if needed to help clarify alternatives and outcomes. Positive options can be indicated with a (+) and negative options with a (-).

Affirm position and act

• Based on your review, determine which of the options is the best. Use the ANA Code for Nurses to support conclusions.
• Use a specific exercise to help check your decision and confirm your thinking.
  • Consider if you told someone you respect about why you chose this option. What would that person say?
  • Write a letter defending your decision to the party with the most to lose.
  • Write a letter to your most serious detractor, explaining why you've made this decision.
• Choose the appropriate action and develop a plan to achieve this action.

Look back

• Evaluate the success of your intervention. Did you consider personal/professional values? Did you apply ethical principles?
• How did the process turn out for all involved? If you had a do-over, are there things that you would have done differently?

Examples

The following are some common ethical dilemmas which you may encounter as a PHN. Consider how you might respond to each. In addition, consider your own feelings and biases when addressing these scenarios.

1. You arrive at a client's home for a visit late on a Friday afternoon. This single mother of three tells you she does not know what she will do for the weekend because she is out of food and has no one to help her. You know she is new to town and does not have an established support network. Her WIC and SNAP are used for the month. The food shelf is closed until Monday. She asks you if you know anyone that she can borrow money from.

Should you loan/give her the money? Should you go purchase some food? Knowing this would not be a financial hardship for you, what is your role as a nurse?

2. One of your prenatal clients informed you that she does not plan to immunize her baby. Her husband objects to "putting poison in the baby." Although she has been interested in your education on the topic, she is afraid of disagreeing with her husband. You know there is a history of domestic violence.

Should you encourage immunizations? If the baby doesn't get immunized, is this medical neglect? Do you need to report this to anyone?

3. A PHN refuses to get vaccinated and is expected to work with you in the COVID clinic.

Should the PHN be assigned to the COVID clinic? How does the risk of spreading the illness to the vulnerable impact your feelings about this PHN? How do you continue working with this nurse? 

4. An elderly client pays his grandson $100 a week to drive him to the grocery store and pharmacy. The client does not have enough money to pay for his newly prescribed insulin and is afraid that if he tells his grandson that he can't pay him, he will quit coming to help.

Is the client a vulnerable adult? Is this financial exploitation? Do you need to report it?

5. One of your clients with tuberculosis has personal care assistant (PCA) services provided by her daughter. You arrive one day to find the client lying on a mattress on the living room floor and "can no longer walk," although there are no other symptoms that would indicate a health concern, and the client was walking at the last visit. You learn that someone is coming to evaluate for additional PCA hours later that day. If she is allowed additional hours, her daughter can make extra income and not have to get a second job.

Is this fraud? Do you need to report it to anyone? Is this client a vulnerable adult?

6. You worked with a client throughout her pregnancy and now postpartum while she is establishing breastfeeding. She told you that she smokes "weed" occasionally to deal with the anxiety of being a new mother. Generally, she smokes in the evening when her boyfriend is home from work and can help with the baby.

What concerns do you have? Would your concerns be the same if she was still pregnant? Is this a child protection issue?

7. You are a public health nurse working in a small community with limited vaccine supplies during a pandemic. The vaccine is a critical tool in preventing the spread of disease and saving lives. However, there's a shortage of vaccines, and you must decide who gets vaccinated first. 

Which ethical principles (e.g., justice, beneficence, autonomy) should guide the decision-making process for vaccine prioritization? How can these principles be balanced when making difficult decisions about who receives the limited vaccine supply?

8. Health education and privacy: You are conducting a health education campaign to promote safe sexual practices among teenagers in the community. However, some parents express concerns about the information's explicit nature.

How can you balance the need for accurate and explicit health education with the concerns of parents who might find the content uncomfortable? What strategies can be employed to ensure both teenagers' autonomy and parental concerns are respected?

9. Contact Tracing and Confidentiality: You are involved in contact tracing efforts during a disease outbreak. You discover that one of the infected individuals is a well-known community figure. Revealing this information could lead to stigmatization.

How can you maintain the confidentiality of infected individuals while still ensuring effective contact tracing? What steps can be taken to minimize the potential for stigmatization of individuals who test positive for a disease?

10. Limited Resources and Equity: Your community health center has limited resources, and you must decide which health services to provide. There's a debate about allocating resources to chronic disease management or preventive services that benefit the whole community.

How can you prioritize between chronic disease management and preventive services while considering health equity and the community's overall well-being? Are there innovative ways to optimize resource utilization to address both immediate health needs and long-term community health goals?

11. Mandatory Vaccination and Autonomy: A new vaccine becomes available to combat a disease outbreak, and public health officials are considering making it mandatory for all community members. Some individuals are concerned about their autonomy being violated.

What ethical considerations should guide the decision to make a vaccine mandatory? How can public health authorities balance the need for community protection through widespread vaccination with respecting individuals' autonomy and choices?

12. Health Disparities and Cultural Sensitivity: You are a public health nurse working in a diverse urban community with a significant immigrant population. The community has high rates of preventable chronic disease, which is exacerbated by unhealthy lifestyles and a lack of awareness about healthy behaviors. While planning a health education campaign, you realize that the standard educational materials and approaches might not effectively reach all cultural groups within the community. Balancing the need to address health disparities and promote cultural sensitivity becomes a challenging ethical dilemma.

What ethical responsibilities do public health nurses have in addressing health disparities within culturally diverse communities? How does cultural sensitivity align with the principle of social justice in healthcare?

13. You are a public health nurse working in a community health clinic in a town with high smoking rates. The local government is considering implementing a tobacco-free policy that would ban smoking in all public areas, including parks, streets, and outside the clinic. As a nurse, you are concerned about the health and well-being of the community, especially vulnerable populations like pregnant women and children, who are disproportionately affected by secondhand smoke. However, you also value patient autonomy and individual choices.

How can nurses navigate the tension between promoting health and respecting personal autonomy? How can nurses evaluate the ethical impact of their decisions and actions, both at the individual patient level and at the community level, in the context of tobacco-free policies? What frameworks or ethical principles should guide nurses in addressing these dilemmas?
 

More information

You can find more information on the MORAL Model at:

Krueger, D. (2008). Ethical decision making in neurosurgery: A case study. Journal of Neuroscience Nursing, 40(6), 346-349.

References

American Nurses Association (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: American Nurses Association.

American Nurses Association, (2013). Public health nursing: Scope and standards of practice (2nd ed.). Silver Springs, MD: American Nurse Association.

Krueger, D. (2008). Ethical decision making in neurosurgery: A case study. Journal of Neuroscience Nursing, 40(6), 346-349.