Enduring Ethical Issues: Looking Back, Looking Forward

Ethical issues are part of everyday critical care nursing practice. Many historical issues, such as how we navigate differences in perspectives about treatment goals and end-of-life care, persist. Other ethical issues that we encounter have new dimensions that reflect the evolutions within health care and society. For example, issues of structural racism, which are deeply embedded and pervasive, have become more conspicuous in recent years, requiring new paradigms to dismantle inequities. Cultivating the skills and resources to recognize and address ethical issues is foundational to preserving personal, professional, and relational integrity.

This symposium of republished articles reflects the consistency of ethical issues over time, as well as the nuances that have emerged, particularly as a result of the COVID-19 pandemic. In the first article, Milliken and Uveges focus on the renewed attention during COVID-19 to how nurses and other providers ought to respond to individual preferences and choices about vaccines amid heighted antivaccine sentiments. Vaccination during the pandemic revealed the complex challenges of responding from a place of respect and fairness, even when misinformation is being propagated through traditional and social media.

In the second article, Kennedy et al highlight the issue of potentially inappropriate treatment in health care and the inadequate attention given to underlying issues such as team dynamics and organizational factors that compound this issue. The authors highlight the persistent challenges and consequences of potentially inappropriate treatment and offer clarifications about key ethical considerations and how to balance these when making decisions about such treatments. Further, Kennedy et al suggest that despite targeted efforts to address common treatment patterns within critical care, multipronged efforts are still necessary.

Rushton et al call attention to the consequences of these persistent ethical issues. Moral injury, first described in the military context, emerged as a concept to describe the depth of moral suffering that clinicians experienced during the pandemic and in its aftermath. Symptoms of a more corrosive form of moral suffering, moral injury, also became pronounced during the COVID-19 pandemic. Moral suffering, whether called moral distress or moral injury, points to the pervasive pattern of clinician responses to a variety of sources of moral adversity. Drawing on historical patterns, the authors illuminate the sources, consequences, and strategies to address moral injury. The consequences of moral suffering are not new, but the prevalence and depth of their impact on the nursing and health care workforce created a renewed urgency to develop evidence-informed systemic solutions.

One leverage point for restoring clinician’s moral agency is to expand their repertoire of tools to address ethical challenges. Ethical decision-making models are particularly useful when addressing systemic issues such as racism and bias in health care. Kalevor et al describe how the pandemic and the coincident public examples of harms toward people of color intensified the need to initiate greater awareness of these issues and their impact within health care environments. Instead of dismissing such instances as infrequent, the authors invite nurses to consider how these issues play out in our everyday practice and how using a common framework can support a more proactive approach to antibiased and antiracist care.

In “Applying E-PAUSE to Ethical Challenges in a Pandemic,” Rushton et al describe another systematic process for approaching ethical concerns at the bedside. E-PAUSE includes the following components: E, ethical context; P, perspective taking; A, ask questions; U, utilize resources; S, stand up and speak up; and E, empower my practice. Each element invites reflection and discernment for ethically supportive action. Regularly applying frameworks such as E-PAUSE creates opportunities for building moral efficacy and confidence in spite of the uncertainty and confusion typically present in the critical care setting.

Finally, a pervasive issue within nursing before the pandemic, but intensified during it, is a reluctance to invest in resources to support nurses’ self-stewardship. Many high-functioning and committed nurses have found that asking for support and resources is interpreted by their institutions as weakness or failure, which triggers shame, guilt, or resistance in the nurses themselves. Bergman and Rushton reframe this idea of resource-seeking as weakness and emphasize nurses’ ability to ask for and receive resources to support their well-being and integrity, encouraging them to turn toward their inherent humanity with greater compassion and wisdom. Doing so is a vital dimension of self-stewardship.

Taken together, this series of articles reminds us of the ubiquitous nature of moral and ethical conundrums, as well as common sources and consequences. It invites a renewed commitment to foster our individual capacities to meet them in contemporary times. As a result, nurses can contribute to the dismantling of the disempowering and harmful patterns that create these challenges in society and within health care organizations.