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Ethical Problems Experienced by Psychiatric Nurses in Korea
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Ethical Problems Experienced by Psychiatric Nurses in Korea Kwisoon Choe, Eun-Ju Song, and Chun-Hwa Jung This study aimed to explore the ethical problems experienced by psychiatric nurses in a clinical setting. Data were collected using semistructured interviews with a purposive sample of 12 female psychiatric nurses from 3 psychiatric facilities in Korea. A thematic content analysis was used to identify ethical problems. The study illustrated 5 categories of ethical problems: moral unpreparedness and blindness, moral numbness, moral complacency, moral conflict, and moral stress. This study provides a theoretical basis of psychiatric ethical problems for developing ethical guidelines that will enable psychiatric nurses to make decisions reasonably and behave ethically in their workplace. © 2012 Elsevier Inc. All rights reserved.
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SYCHIATRIC NURSES ENCOUNTER a variety of ethical issues during their everyday practice (Johnstone, 2009), especially regarding the use of compulsory treatments (e.g., restraints, isolation in a seclusion room, compulsory admission and discharge, and compulsory medication). Although psychiatric nurses may be willing to accept compulsory treatments as an essential part of their job, some remain uncomfortable with their use (Bigwood & Crowe, 2008). In addition, psychiatric nurses may experience high anxiety levels because of conflicts between their role in helping those with mental illnesses and the idea of controlling them at the same time (Howell & Norman, 2000). Psychiatric staff members have developed multiple interventions (e.g., state policy and regulation changes, practice context examination, and employing additional staff) in order to reduce the use of seclusion on patients (Gaskin, Elsom, & Happell, 2007). However, the ethical guidelines and strategies for patient restriction remain insufficient in many psychiatric facilities (Cho, 2005; Leung, 2002). Because of the nature of psychiatric illnesses, people with mental health problems lack the ability to adequately express their own rights and opinions; thus, psychiatric nurses may feel pressured to make such ethical decisions for their patients (Cho, 2005).
In Korea, the Mental Health Act was established in 1995 to protect the rights of people with mental illnesses, such as the right to be respected as a human being, the right to be treated fairly, and the right to act as autonomously as possible. As such, psychiatric nurses became more concerned about the legality of their nursing practices. Therefore, psychiatric nurses now have both the legal and the ethical responsibility to effectively identify and respond to their patients' problems. The nurse must then be aware of the different types of ethical problems they can encounter and the methods to resolve them (Johnstone, 2009). By reviewing international and national studies on the ethics of psychiatric nurses, we learned that
From the Department of Nursing, Kunsan National University, Jeollabuk-do, Republic of Korea; Department of Nursing, Wonkwang University, Jeollabuk-do, Republic of Korea; and Department of Nursing, Wonkwang Health Science University, Jeollabuk-do, Republic of Korea. Corresponding Author: Kwisoon Choe, PhD, RN, Associate Professor, Department of Nursing, Kunsan National University, 558 Daehangno, Gunsan, Jeollabukdo, 573-701, Republic of Korea. E–mail address: [email protected] © 2012 Elsevier Inc. All rights reserved. 0883-9417/1801-0005$34.00/0 http://dx.doi.org/10.1016/j.apnu.2012.04.002
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the majority of research has been on compulsory treatments (Bigwood & Crowe, 2008; Cho, 2005; Clark & Bowers, 2000; Kontio et al., 2010; Leung, 2002; Radden, 2002). More specifically, research has focused on the ethical problems (Radden, 2002), moral distress (Lützén, Blom, Ewalds-Kvist, & Winch, 2010; Ohnishi et al., 2010), and moral commitment (Sjöstedt, Dahlstrand, Severinsson, & Lützén, 2001) of psychiatric nurses and moral considerations (Abma & Widdershoven, 2006) and ethical guidelines (Koivisto, Janhonen, Latvala, & Väisänen, 2001) in nursing care. In Korea, there are two studies on psychiatric nurses' ethical issues: the ethical problems perceived by psychiatric nurses (Cho, 2005) and nurses' perceptions in ethical conflict situations (Park, 2004). These studies provided the basis for our study in showing that Korean psychiatric nurses encountered various ethical problems and experienced ethical stress. The purpose of this study was to explore psychiatric nurses' ethical problems from their perspective and then classify the problems by type. This study will provide a theoretical basis for developing ethical guidelines that will enable psychiatric nurses to make decisions that are more reasonable and to behave ethically in their workplaces.
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▪ THEORETICAL FRAMEWORK
This study sought to analyze the ethical problems faced by psychiatric nurses in a clinical setting, using the theoretical analysis framework of ethical problems suggested by Johnstone (2009). This analysis framework was more detailed and appropriate to nursing situations than the more popular Four Principles of Biomedical Ethics by Beauchamp and Childress (2009). Generally, researchers have represented nursing ethical problems as ethical dilemmas (Johnstone, 2009); however, this is not true for all the ethical problems nurses typically experience. Nursing ethical problems must be more specifically defined, in addition to ethical dilemmas. As such, Johnstone proposed the following 10 problems commonly faced by psychiatric nurses: ▪ Moral unpreparedness—people may be unprepared to deal appropriately and effectively with complex, morally troubling situations. ▪ Moral blindness—people may not see problems as being moral, rather they may perceive
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them as being either clinical or technical problems. Moral indifference—people may be unconcerned or uninterested about moral demands. Amoralism—characterized by an absence of moral concern and a rejection of morality altogether. An amoral person refrains from making moral judgments and displaying moral behaviors. Immoralism—people may deliberately violate the standard norms of ethical professional conduct or the general ethical standards of conduct toward others, also known as moral turpitude and moral delinquency. Moral complacency—characterized by a general unwillingness to accept that one's moral opinions may be mistaken. Someone exhibiting moral complacency does not question his or her assumptions and does not regard one's own point of view as just one of many to be compared, contrasted, and considered. Moral fanaticism—this is similar in many respects to moral complacency; the moral fanatic is someone who is thoroughly wedded to certain ideals and who uncritically, and without reflection, makes moral judgments. Moral disagreement—this is characterized by disagreement in the selection, interpretation, application, and evaluation of moral standards among a group of people (e.g., two people may agree to common moral standards but disagree about how to act when these standards come into conflict). Moral dilemma—a situation that requires choosing between what seems to be two equally desirable or undesirable alternatives and is also described as an awful feeling of “being stuck” (e.g., logical incompatibility between two different moral principles, competing moral duties, and competing or conflicting interests). Moral stress, moral distress, and moral perplexity—people experience psychological disequilibrium and negative feelings when making a moral decision but do not go ahead with it.
In this study, we grouped these 10 problems into five categories based on similarity and relevance. First, moral unpreparedness and moral blindness were combined into “moral unpreparedness and
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blindness” because the former often begets the latter. Second, moral indifference, amoralism, and immoralism are all problems with the sensing of morality; thus, we grouped them under the heading of “moral numbness.” Third, moral fanaticism is an extreme case of moral complacency; thus, we grouped them into just “moral complacency.” Fourth, we combined moral disagreement and moral dilemma into “moral conflict.” Finally, moral stress remained as it was. METHOD
Research Design This was a descriptive and exploratory study. We conducted focus group interviews with psychiatric nurses in Korea in order to explore their experience of ethical problems in psychiatric mental health nursing. The study utilized a qualitative content analysis described by Patton (2002) to identify the themes from the nurses' experiences. Participants The participants were 12 female psychiatric nurses working in three psychiatric facilities (two psychiatric hospitals and a psychiatric rehabilitation center). Two of the authors were advisory committee members of these psychiatric facilities. We recruited participants through introduction from a chief or a head nurse from the psychiatric hospitals and the center. Their mean age was 31.6 years (range = 24–39 years), and their mean working experience as a psychiatric nurse was 6.4 years (range = 11 months to 11 years). Ethical Considerations Participants were informed of the purpose of the study, data collection procedure, risk-to-benefit ratio, and confidentiality and were assured that they could withdraw from this study at any time. The participants understood the purpose of this study and participated voluntarily because they recognized the significance of the study for the benefit of ethical nursing care in psychiatric settings. A written consent form was obtained from each participant, and each gave permission for us to type interview transcripts. Data Collection In order to collect qualitative data on the ethical problems, we used focus group interviews. Our
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rationale for using focus group interviews was that it was more likely to obtain abundant data about these ethical problems by avoiding direct self-disclosure and, instead, brainstorming in a group discussion. To help the psychiatric nurses fully consider the ethical issues of their nursing practice, we sent an e-mail to each participant a week prior to the focus group, which included interview questions such as, “Do you experience ethical problems in your practice?” However, although the interview questions were provided a week before the interview, the participants did not know how to express knowledge of their ethical issues. When participants hesitated to speak about their ethical issues, researchers asked probing questions (e.g., “What do you think about compulsory treatments such as restraints, seclusion, or compulsory admission?”) to facilitate their reflections. Data Analysis We used a qualitative thematic analysis (Patton, 2002) to investigate the participants' moral problems. Data sources included literature reviews and transcription notes from the focus group interviews. Taped interviews were transcribed verbatim. The authors reviewed the transcripts together line by line after each interview and coded the data. Both inductive and deductive analyses were applied during the thematic analysis (Patton, 2002). A qualitative analysis is typically inductive in the early stages, especially during the development of a codebook for content analysis or for deciphering possible categories, patterns, and themes. Inductive analysis involves discovering patterns, themes, and categories in one's data (Patton, 2002). During the initial analysis process, we fractured the data to look at the similarities and differences revealed by the inductive analysis. Once inductive analysis had revealed the themes, they were deductively categorized into 10 moral problems on the basis of Johnstone (2009). For example, the themes “immature control of nurses' own feeling” and “uncertainty of whether patients' symptoms are real” were categorized under “moral unpreparedness” through several discussions between the authors. We also considered the relationships between the themes during the deductive analysis. However, it is difficult to categorize moral problems experienced by psychiatric nurses according to Johnstone. Although the authors discussed the type of moral problems faced by psychiatric
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nurses several times, for example, we did not find moral fanaticism in any of the nurses in the sample. RESULTS
Interviews with the psychiatric nurses revealed five interrelated themes: moral unpreparedness and blindness, moral numbness, moral complacency, moral conflict, and moral stress. Moral Unpreparedness and Blindness Participants experienced moral unpreparedness when they had difficulty regulating their negative feelings about psychiatric patients who acted out when they were examining the patient's mental status. Participants said that because they became angry with the patient and were unable to control their anger, it was difficult to provide the best nursing care. New nurses in particular found that it was difficult to properly deal with patients' various problems, such as aggressive or sexual behaviors, because of their lack of clinical experience and emotional regulation. One new nurse described a difficult situation she had experienced with a patient with a conduct disorder: “A patient with whom I thought I had developed a rapport suddenly refused his evening medication. I asked him why, but he had no answer. I felt hurt and confused. I never approached him again until he was discharged.” Because the new nurse did not thoroughly assess the patient's mental status, she had trouble giving him proper care. When psychiatric nurses are not prepared to deal with complex ethical situations in a clinical setting, they are often subject to moral blindness— an inability to recognize moral problems in certain situations. Participants in this study seemed to prioritize their nursing work over the psychiatric patient's human rights because of mistakenly thinking that psychiatric patients were without full human rights. Because they did not know that psychiatric patients have legal rights like suffrage, they often neglect to allow patients these rights, particularly in a psychiatric inpatient unit. Some participants applied compulsory treatments (e.g., compulsory admission and discharge, medication, restraints, seclusion, and compulsory bathing) without consideration of the psychiatric patients' human rights and did not maintain patient confidentiality. The medical staff sometimes treated the personal and family histories of the patients as gossip and did not realize the ethical ramifica-
tions of posting patients' photos on the hospital homepage or in a newsletter, which violated the patients' confidentiality. Participants thought it was natural for compulsory treatments to be given to patients against their will and for patients' symptoms to be controlled with medications to prevent symptom aggravation or aggressive behaviors. This perception may have been because of a lack of disease awareness. The nurses believed that psychiatric medications were safe. Moreover, the participants thought that psychiatric patients should be hospitalized forcefully, even if against their will, on the grounds of serious symptoms or even just because they had a mental illness. When they applied restraints and seclusion treatments to psychiatric patients, they tended to consider them behavior modification therapies, without respecting the patients' opinions or rights. In fact, they used restraints and isolation even when patients were easily controlled. The important fact was that they did not recognize that such compulsory nursing could become an ethical problem itself. Moral Numbness When caring for patients with chronic mental illnesses who showed repeated psychotic symptoms, some participants reported being indifferent to both symptom changes and medication regulation. One nurse stated, “I ignore patients who repeat the same words to get attention.” Even in situations in which patients were discharged for economical reasons without symptom improvement, participants reported that they did not feel anything. Participants whose patients acted out showed amoral behaviors because of countertransference. For them, the use of restraints was natural, and each participant wanted negative behaviors to occur only during other nurses' shifts and not on their own working hours. Participants tended to think that aggressive patients should not be hospitalized because they could cause problems in the ward. They also believed that it was natural to apply restraints longer than recommended on such patients, as reflected by one nurse who said, “Why do I care for this patient? I think that if the patient is compelled to suffer, it is a deserved result and a correct treatment.” Some participants displayed immoralism by not reporting mistakes or errors made in their nursing care, such as prescribing medications without the
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doctor's consent, having knowledge of doctors' malpractice, or being aggressive with the patient. Similarly, they claimed that they did not speak frankly about fellow nurses' malpractice, failed to comply with aseptic technique practices, and did not report mistakes or errors in medication. Some participants would record that a patient's condition had been identified, even if it had not. Some participants gave placebo treatments without a doctor's permission, administered a digestive to a patient requiring sleeping pills, ignored PRN (PRN is a shortened form of the Latin phrase pro re nata) orders, or gave normal saline to a patient requiring a painkiller, all without doctor's consent. In some cases, after a patient suicide or disappearance, participants were willing to accept a doctor's suggestion of fabricating the patient's chart. Moral Complacency Some participants showed moral complacency with regard to the compulsory treatments applied to the psychiatric patient and PRN orders. Participants considered medication as the best policy, regardless of the patient's autonomy, in order to improve the patient's symptoms. Some participants thought that compulsory restraints were the best treatment for patients who were more likely to bring harm to themselves or others. Others stuck to their own perceptions of the patient's condition, such as in the example of PRN administration of sleeping pills given above. Some participants also assumed that patients who wandered at night should be administered sleeping pills. Conversely, some of the nurses thought that administering sleeping pills might contribute to a patient's addiction, so they did not give them even if the patient's condition did require them. Moral Conflict The participants experienced four types of moral disagreements, including moral disagreements against hospital administrative policies, doctors, colleagues, patients, and patients' significant others. Moral disagreements between hospital administrative policies and nurses occurred because of hospitals preferring their own interests to improve patient rights (e.g., addressing shortage of nursing staff, old facilities, and using the benefits of prolonged hospitalization). Moral disagreements between doctors and nurses occurred when the doctors inconsistently applied restraints and seclu-
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sion. Doctors' orders were also inconsistent among doctors in the same situation. Moral disagreements between nurses occurred when nurses working together had different strategies for managing their patients' symptoms. For example, one nurse accepted all of a patient's repeated requests, whereas the other nurse did not. Disagreements arose between nurses and a patient's significant other when a patient was discharged by his or her family despite needing further treatment, when the patient's significant other hospitalized a patient who was not a danger to self or others, or when a patient's significant other did not discharge the patient once his or her condition had improved. Participants had moral dilemmas in situations in which the patient's significant other began the admission procedure and ignored the patient's autonomy or when the doctors made a unilateral decision about whether the patient was allowed to make a telephone call, have visitors, or take a walk. Such dilemmas also occurred when doctors decided they should apply restraints and seclusion or prohibited sexual behaviors such as kissing, intimate touching, exposure, and intercourse between patients without considering patients' autonomy. Moreover, participants had moral dilemmas regarding the use of compulsory restrictions as a way to resolve a dangerous situation or invasions of human rights and privacy. For example, although they should monitor all patients in the seclusion rooms with closed-circuit TV monitoring screens, they experienced moral dilemmas about the fact that they violated these patients' privacy, especially when patients changed their sanitary napkins or used the toilet. Participants also had dilemmas about controlling patients' sexual problems and whether medical staff should make decisions about controlling patients' natural sexual feelings. They also experienced moral dilemmas about how to maintain safe environments for patients when using toilets without a door handle and shower rooms made of transparent glass without violating patients' privacy and human rights. Moral Stress Participants experienced moral stresses such as powerlessness, frustration, guilt, and agony when confronting the moral disagreements and dilemmas presented above. In particular, they felt frustration
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when being required to unconditionally accept decisions made by patients' significant others or doctors. One participant said, “I felt powerless to see that patients' families transfer patients whose condition did not require them to be admitted to another psychiatric hospital, instead of discharging them.” Participants sometimes experience agony when applying compulsory restrictions to patients who refuse their treatment and feel guilty when watching these patients complain of pain during the restraint period. One participant described this stressful feeling of ambivalence: “I explain the necessity of the restraint to the patients while questioning the necessity of the restraint in my mind.” DISCUSSION
From the results of this study, we found that moral unpreparedness and blindness and moral numbness led to immoral behaviors, whereas unresolved moral conflicts often caused moral stress for psychiatric nurses. Nurses who had just started their careers or had limited knowledge of psychiatric nursing care experienced the highest incidence of moral unpreparedness and moral blindness. In particular, because new nurses were not confident about their own moral judgment, they experienced confusion and ultimately followed the views of senior nurses (Park, 2004). This finding is consistent with the fact that a nurse's status and career are connected with the decision-making and coping methods employed in the face of moral issues (Ahn, Kim, Cho, Um, & Lee, 2004); the more experienced a nurse is, the more knowledge he or she has regarding moral issues. It is necessary to educate new nurses about the ethics of psychiatric nursing and coping methods for the moral issues they will encounter. Furthermore, more experienced psychiatric nurses should share their knowledge, skills, and experiences with new nurses to help them further develop their moral decision-making skills. This study shows that concepts, such as moral indifference and moral complacency, reflect the unique ethical problems in psychiatry. Participants showed moral indifference toward patients with chronic mental illnesses, especially those who had been hospitalized for long periods. This is in line with current research, which found that psychiatric staff members are more likely to think that they do not respect the autonomy and rights of patients
with severe symptoms, if those patients were hospitalized long term (Ohnishi et al., 2010). After Korea enacted the Mental Health Act in 1995, it has strived to conduct deinstitutionalization, but the actual duration of hospitalization in psychiatric hospitals was an average of 245 days (Lee, Oh, & Park, 2008), compared with a week in the United States and 11 weeks in the United Kingdom (The Japan Times, 2011). Long-term hospitalization is thus a national issue that requires systematic improvement. We suggest the establishment of more specific resolutions, including creating a workplace rotation system or an off-day system, that will provide nurses with time to reflect their own nursing practice and thus enhance their potential for ethical practice. Moral numbness, if left unresolved, can cause serious problems, resulting in moral or legal disputes with patients and their families. Some participants in this study showed immoral behaviors, due primarily to a lack of early efforts to correct their numbed sense of morality. Immoral behaviors that are not corrected during a nurse's early career tend to get worse as time passes, so education programs to correct these behaviors are urgently needed, especially for new nurses. Worse yet, these nurses may not know that such behaviors constitute immoralism. Thus, psychiatric nurses require rigorous training to ensure that they do not overlook even trivial moral problems in order to prevent future immoral behaviors. Although the current nursing curriculum in Korea includes education for legally and ethically desirable nursing standards and practice, it must also include teaching of other significant, yet still underaddressed, issues such as moral unpreparedness and moral numbness. If these issues are left untreated, it will result in moral indifference, followed by various further moral problems. Cooperation with colleagues and employing institutions are important for nurses, but they can sometimes cause conflicts with their responsibility as an advocate of the patient's rights (Fry & Johnstone, 2002). Psychiatric nurses in this study felt conflicted about moral disagreements and reluctantly complied with hospital policies and doctor's directives, even when they realized that such directives were unjust. Although nurses have excellent judgments and abilities, they assume an attitude of passive conformity according to the traditional cultural norms of their job (Meyers,
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2002). When nurses ignore their own moral judgments in favor of a doctor's authority, hospital policies, or legal restrictions, they often experience psychological pain and discomfort (Kälvemark, Höglund, Hansson, Westerholm, & Arnetz, 2004). Neglecting moral disagreements causes even greater moral stress. Moral conflicts were the most common problem faced by the participants in this study. The most difficult moral conflicts represented in this study included restraints and isolation, compulsory admission and discharge, and privacy violation. The compulsory admission rate of Korean mental health facilities is 87% (Kwon, 2010), although compulsory treatment has not been identified in current statistics (Cho, 2005). Patients with psychiatric illness do not have self-determination, their privacy is not protected, and they experience serious human rights violations. Because psychiatric moral conflicts are mainly caused by compulsory treatments, other methods are being studied as possible ways to control the behaviors of aggressive psychiatric patients (Gaskin et al., 2007), but there are currently few options outside compulsory treatment (Foster, Bowers, & Nijman, 2007). It is likely that there will be alternatives to reduce moral conflicts, allowing psychiatric nurses to create clear guidelines and regulations and establish a therapeutic environment that respects their patients' human rights (Kontio et al., 2010). Similarly, psychiatric nurses need emotional support so that they do not feel guilty about compulsory treatment. Moral stress manifests as physical symptoms, such as fatigue and sleep deprivation, and as psychological symptoms, such as feelings of helplessness, guilt, and remorse. These moral stresses eventually trigger burnout (Ohnishi et al., 2010). Participants in our study did not overcome moral conflicts, instead they reported feelings of depression and high hospital turnover. A study related to moral stress reported that nurses did not overcome their stress and, instead, resigned from their jobs (Corley, Elswick, Gorman, & Clor, 2001). In another study, nurses who perceived intense moral distress reported feeling unsafe in their workplace (Pauly, Varcoe, Storch, & Newton, 2009). Thus, it is necessary for nurses to relieve their distress through professional help such as counseling and vacation. However, there is currently nowhere for psychiatric nurses to discuss moral stress professionally (Cho, 2005), and nurses
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who failed overcome their stressful situations changed jobs. Support systems must be incorporated into institutional systems to prevent and relieve psychiatric nurses' moral stress. CONCLUSION
This study described the ethical problems experienced by psychiatric nurses working in psychiatric facilities in Korea. Psychiatric nurses experienced the most moral problems in situations of applying compulsory treatments or when violating the psychiatric patients' human rights and autonomy. Participants in this study experienced a conflict between playing the role of a patient advocate and the role of a doctor's assistant. They experienced moral stress because they felt that they should respect the patients' human rights and autonomy but were unable to do so. We must find various ways to maintain patients' human rights and autonomy in order for the psychiatric nurses to be able to support them. The findings in this study suggest some implications for nursing practice, research, education, and administration. First, changes must be made in nursing practice to provide accurate and consistent moral guidelines about diverse moral problems in the field of nursing. In addition, a cooperative system and a culture of good communication must be established between psychiatrists and psychiatric nurses in order to enhance the patients' welfare and reduce psychiatric nurses' moral difficulties. Researchers must explore psychiatric nurses' moral decision-making processes, which will provide a theoretical basis for improving nurses' moral behavior. Researchers must also examine differences between the moral experiences of psychiatric nurses and those of other clinical nurses. Such comparative analyses will identify moral problems specific to psychiatric nurses and, thus, help develop programs appropriate for them. Hospitals need to provide psychiatric nurses with educational programs that help them make the best ethical decisions in complex clinical situations. The programs should be prepared and developed in conjunction with legal and medical experts in order to provide the most effective approaches to the legal and moral problems of nursing. Hospitals should also provide professional counseling for psychiatric nurses to ventilate their moral stress. Furthermore, in an effort to prevent the moral disagreements that
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arise between nurses and hospital administration, hospital administrators should strive to create moral administrative procedures and to improve nurses' working conditions. REFERENCES Abma, T. A., & Widdershoven, G. A. (2006). Moral deliberation in psychiatric nursing practice. Nursing Ethics, 13, 546–557, http://dx.doi.org/10.1191/0969733006 nej892oa. Ahn, S. H., Kim, Y. S., Cho, G. C., Um, Y. R., & Lee, S. H. (2004). Ethical problems experienced by nurses and nursing needs ethics guidelines. The Korean Nurse, 43(6), 52–69. Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics. New York, NY: Oxford University Press. Bigwood, S., & Crowe, M. (2008). ‘It's part of the job, but it spoils the job’: A phenomenological study of physical restraint. International Journal of Mental Health Nursing, 17, 215–222, http://dx.doi.org/10.1111/j.14470349.2008.00526.x. Cho, M. J. (2005). Case on analysis on ethical problems perceived by nurses at psychiatric inpatient setting. (Unpublished doctoral dissertation). Ewha Woman's University, Seoul. Clark, N., & Bowers, L. (2000). Psychiatric nursing and compulsory psychiatric care. Journal of Advanced Nursing, 31, 389–394. Corley, M. C., Elswick, R. K., Gorman, M., & Clor, T. (2001). Development and evaluation of a moral distress scale. Journal of Advanced Nursing, 33, 250–256. Foster, C., Bowers, L., & Nijman, H. (2007). Aggressive behaviour on acute psychiatric wards: Prevalence, severity and management. Journal of Advanced Nursing, 58, 140–149. Fry, S. T., & Johnstone, M. (2002). Ethics in nursing practice. (2nd ed.). Malden, MA: Wiley-Blackwell. Gaskin, C., Elsom, S. J., & Happell, B. (2007). Interventions for reducing the use of seclusion in psychiatric facilities: Review of the literature. The British Journal of Psychiatry, 191, 298–303, http://dx.doi.org/10.1192/ bjp.bp.106.034538. Howell, V., & Norman, I. (2000). Steering a steady course in an era of compulsory treatment: Taking mental health nursing into the millennium. Journal of Mental Health, 9(6), 605–616. Johnstone, M. J. (2009). Bioethics: A nursing perspective. Chatswood, NSW: Churchill Livingstone. Kälvemark, S., Höglund, A. T., Hansson, M. G., Westerholm, P., & Arnetz, B. (2004). Living with conflicts–ethical
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Ethical Problems Experienced by Psychiatric Nurses in Korea Kwisoon Choe, Eun-Ju Song, and Chun-Hwa Jung This study aimed to explore the ethical problems experienced by psychiatric nurses in a clinical setting. Data were collected using semistructured interviews with a purposive sample of 12 female psychiatric nurses from 3 psychiatric facilities in Korea. A thematic content analysis was used to identify ethical problems. The study illustrated 5 categories of ethical problems: moral unpreparedness and blindness, moral numbness, moral complacency, moral conflict, and moral stress. This study provides a theoretical basis of psychiatric ethical problems for developing ethical guidelines that will enable psychiatric nurses to make decisions reasonably and behave ethically in their workplace. © 2012 Elsevier Inc. All rights reserved.
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SYCHIATRIC NURSES ENCOUNTER a variety of ethical issues during their everyday practice (Johnstone, 2009), especially regarding the use of compulsory treatments (e.g., restraints, isolation in a seclusion room, compulsory admission and discharge, and compulsory medication). Although psychiatric nurses may be willing to accept compulsory treatments as an essential part of their job, some remain uncomfortable with their use (Bigwood & Crowe, 2008). In addition, psychiatric nurses may experience high anxiety levels because of conflicts between their role in helping those with mental illnesses and the idea of controlling them at the same time (Howell & Norman, 2000). Psychiatric staff members have developed multiple interventions (e.g., state policy and regulation changes, practice context examination, and employing additional staff) in order to reduce the use of seclusion on patients (Gaskin, Elsom, & Happell, 2007). However, the ethical guidelines and strategies for patient restriction remain insufficient in many psychiatric facilities (Cho, 2005; Leung, 2002). Because of the nature of psychiatric illnesses, people with mental health problems lack the ability to adequately express their own rights and opinions; thus, psychiatric nurses may feel pressured to make such ethical decisions for their patients (Cho, 2005).
In Korea, the Mental Health Act was established in 1995 to protect the rights of people with mental illnesses, such as the right to be respected as a human being, the right to be treated fairly, and the right to act as autonomously as possible. As such, psychiatric nurses became more concerned about the legality of their nursing practices. Therefore, psychiatric nurses now have both the legal and the ethical responsibility to effectively identify and respond to their patients' problems. The nurse must then be aware of the different types of ethical problems they can encounter and the methods to resolve them (Johnstone, 2009). By reviewing international and national studies on the ethics of psychiatric nurses, we learned that
From the Department of Nursing, Kunsan National University, Jeollabuk-do, Republic of Korea; Department of Nursing, Wonkwang University, Jeollabuk-do, Republic of Korea; and Department of Nursing, Wonkwang Health Science University, Jeollabuk-do, Republic of Korea. Corresponding Author: Kwisoon Choe, PhD, RN, Associate Professor, Department of Nursing, Kunsan National University, 558 Daehangno, Gunsan, Jeollabukdo, 573-701, Republic of Korea. E–mail address: [email protected] © 2012 Elsevier Inc. All rights reserved. 0883-9417/1801-0005$34.00/0 http://dx.doi.org/10.1016/j.apnu.2012.04.002
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the majority of research has been on compulsory treatments (Bigwood & Crowe, 2008; Cho, 2005; Clark & Bowers, 2000; Kontio et al., 2010; Leung, 2002; Radden, 2002). More specifically, research has focused on the ethical problems (Radden, 2002), moral distress (Lützén, Blom, Ewalds-Kvist, & Winch, 2010; Ohnishi et al., 2010), and moral commitment (Sjöstedt, Dahlstrand, Severinsson, & Lützén, 2001) of psychiatric nurses and moral considerations (Abma & Widdershoven, 2006) and ethical guidelines (Koivisto, Janhonen, Latvala, & Väisänen, 2001) in nursing care. In Korea, there are two studies on psychiatric nurses' ethical issues: the ethical problems perceived by psychiatric nurses (Cho, 2005) and nurses' perceptions in ethical conflict situations (Park, 2004). These studies provided the basis for our study in showing that Korean psychiatric nurses encountered various ethical problems and experienced ethical stress. The purpose of this study was to explore psychiatric nurses' ethical problems from their perspective and then classify the problems by type. This study will provide a theoretical basis for developing ethical guidelines that will enable psychiatric nurses to make decisions that are more reasonable and to behave ethically in their workplaces.
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▪ THEORETICAL FRAMEWORK
This study sought to analyze the ethical problems faced by psychiatric nurses in a clinical setting, using the theoretical analysis framework of ethical problems suggested by Johnstone (2009). This analysis framework was more detailed and appropriate to nursing situations than the more popular Four Principles of Biomedical Ethics by Beauchamp and Childress (2009). Generally, researchers have represented nursing ethical problems as ethical dilemmas (Johnstone, 2009); however, this is not true for all the ethical problems nurses typically experience. Nursing ethical problems must be more specifically defined, in addition to ethical dilemmas. As such, Johnstone proposed the following 10 problems commonly faced by psychiatric nurses: ▪ Moral unpreparedness—people may be unprepared to deal appropriately and effectively with complex, morally troubling situations. ▪ Moral blindness—people may not see problems as being moral, rather they may perceive
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them as being either clinical or technical problems. Moral indifference—people may be unconcerned or uninterested about moral demands. Amoralism—characterized by an absence of moral concern and a rejection of morality altogether. An amoral person refrains from making moral judgments and displaying moral behaviors. Immoralism—people may deliberately violate the standard norms of ethical professional conduct or the general ethical standards of conduct toward others, also known as moral turpitude and moral delinquency. Moral complacency—characterized by a general unwillingness to accept that one's moral opinions may be mistaken. Someone exhibiting moral complacency does not question his or her assumptions and does not regard one's own point of view as just one of many to be compared, contrasted, and considered. Moral fanaticism—this is similar in many respects to moral complacency; the moral fanatic is someone who is thoroughly wedded to certain ideals and who uncritically, and without reflection, makes moral judgments. Moral disagreement—this is characterized by disagreement in the selection, interpretation, application, and evaluation of moral standards among a group of people (e.g., two people may agree to common moral standards but disagree about how to act when these standards come into conflict). Moral dilemma—a situation that requires choosing between what seems to be two equally desirable or undesirable alternatives and is also described as an awful feeling of “being stuck” (e.g., logical incompatibility between two different moral principles, competing moral duties, and competing or conflicting interests). Moral stress, moral distress, and moral perplexity—people experience psychological disequilibrium and negative feelings when making a moral decision but do not go ahead with it.
In this study, we grouped these 10 problems into five categories based on similarity and relevance. First, moral unpreparedness and moral blindness were combined into “moral unpreparedness and
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blindness” because the former often begets the latter. Second, moral indifference, amoralism, and immoralism are all problems with the sensing of morality; thus, we grouped them under the heading of “moral numbness.” Third, moral fanaticism is an extreme case of moral complacency; thus, we grouped them into just “moral complacency.” Fourth, we combined moral disagreement and moral dilemma into “moral conflict.” Finally, moral stress remained as it was. METHOD
Research Design This was a descriptive and exploratory study. We conducted focus group interviews with psychiatric nurses in Korea in order to explore their experience of ethical problems in psychiatric mental health nursing. The study utilized a qualitative content analysis described by Patton (2002) to identify the themes from the nurses' experiences. Participants The participants were 12 female psychiatric nurses working in three psychiatric facilities (two psychiatric hospitals and a psychiatric rehabilitation center). Two of the authors were advisory committee members of these psychiatric facilities. We recruited participants through introduction from a chief or a head nurse from the psychiatric hospitals and the center. Their mean age was 31.6 years (range = 24–39 years), and their mean working experience as a psychiatric nurse was 6.4 years (range = 11 months to 11 years). Ethical Considerations Participants were informed of the purpose of the study, data collection procedure, risk-to-benefit ratio, and confidentiality and were assured that they could withdraw from this study at any time. The participants understood the purpose of this study and participated voluntarily because they recognized the significance of the study for the benefit of ethical nursing care in psychiatric settings. A written consent form was obtained from each participant, and each gave permission for us to type interview transcripts. Data Collection In order to collect qualitative data on the ethical problems, we used focus group interviews. Our
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rationale for using focus group interviews was that it was more likely to obtain abundant data about these ethical problems by avoiding direct self-disclosure and, instead, brainstorming in a group discussion. To help the psychiatric nurses fully consider the ethical issues of their nursing practice, we sent an e-mail to each participant a week prior to the focus group, which included interview questions such as, “Do you experience ethical problems in your practice?” However, although the interview questions were provided a week before the interview, the participants did not know how to express knowledge of their ethical issues. When participants hesitated to speak about their ethical issues, researchers asked probing questions (e.g., “What do you think about compulsory treatments such as restraints, seclusion, or compulsory admission?”) to facilitate their reflections. Data Analysis We used a qualitative thematic analysis (Patton, 2002) to investigate the participants' moral problems. Data sources included literature reviews and transcription notes from the focus group interviews. Taped interviews were transcribed verbatim. The authors reviewed the transcripts together line by line after each interview and coded the data. Both inductive and deductive analyses were applied during the thematic analysis (Patton, 2002). A qualitative analysis is typically inductive in the early stages, especially during the development of a codebook for content analysis or for deciphering possible categories, patterns, and themes. Inductive analysis involves discovering patterns, themes, and categories in one's data (Patton, 2002). During the initial analysis process, we fractured the data to look at the similarities and differences revealed by the inductive analysis. Once inductive analysis had revealed the themes, they were deductively categorized into 10 moral problems on the basis of Johnstone (2009). For example, the themes “immature control of nurses' own feeling” and “uncertainty of whether patients' symptoms are real” were categorized under “moral unpreparedness” through several discussions between the authors. We also considered the relationships between the themes during the deductive analysis. However, it is difficult to categorize moral problems experienced by psychiatric nurses according to Johnstone. Although the authors discussed the type of moral problems faced by psychiatric
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nurses several times, for example, we did not find moral fanaticism in any of the nurses in the sample. RESULTS
Interviews with the psychiatric nurses revealed five interrelated themes: moral unpreparedness and blindness, moral numbness, moral complacency, moral conflict, and moral stress. Moral Unpreparedness and Blindness Participants experienced moral unpreparedness when they had difficulty regulating their negative feelings about psychiatric patients who acted out when they were examining the patient's mental status. Participants said that because they became angry with the patient and were unable to control their anger, it was difficult to provide the best nursing care. New nurses in particular found that it was difficult to properly deal with patients' various problems, such as aggressive or sexual behaviors, because of their lack of clinical experience and emotional regulation. One new nurse described a difficult situation she had experienced with a patient with a conduct disorder: “A patient with whom I thought I had developed a rapport suddenly refused his evening medication. I asked him why, but he had no answer. I felt hurt and confused. I never approached him again until he was discharged.” Because the new nurse did not thoroughly assess the patient's mental status, she had trouble giving him proper care. When psychiatric nurses are not prepared to deal with complex ethical situations in a clinical setting, they are often subject to moral blindness— an inability to recognize moral problems in certain situations. Participants in this study seemed to prioritize their nursing work over the psychiatric patient's human rights because of mistakenly thinking that psychiatric patients were without full human rights. Because they did not know that psychiatric patients have legal rights like suffrage, they often neglect to allow patients these rights, particularly in a psychiatric inpatient unit. Some participants applied compulsory treatments (e.g., compulsory admission and discharge, medication, restraints, seclusion, and compulsory bathing) without consideration of the psychiatric patients' human rights and did not maintain patient confidentiality. The medical staff sometimes treated the personal and family histories of the patients as gossip and did not realize the ethical ramifica-
tions of posting patients' photos on the hospital homepage or in a newsletter, which violated the patients' confidentiality. Participants thought it was natural for compulsory treatments to be given to patients against their will and for patients' symptoms to be controlled with medications to prevent symptom aggravation or aggressive behaviors. This perception may have been because of a lack of disease awareness. The nurses believed that psychiatric medications were safe. Moreover, the participants thought that psychiatric patients should be hospitalized forcefully, even if against their will, on the grounds of serious symptoms or even just because they had a mental illness. When they applied restraints and seclusion treatments to psychiatric patients, they tended to consider them behavior modification therapies, without respecting the patients' opinions or rights. In fact, they used restraints and isolation even when patients were easily controlled. The important fact was that they did not recognize that such compulsory nursing could become an ethical problem itself. Moral Numbness When caring for patients with chronic mental illnesses who showed repeated psychotic symptoms, some participants reported being indifferent to both symptom changes and medication regulation. One nurse stated, “I ignore patients who repeat the same words to get attention.” Even in situations in which patients were discharged for economical reasons without symptom improvement, participants reported that they did not feel anything. Participants whose patients acted out showed amoral behaviors because of countertransference. For them, the use of restraints was natural, and each participant wanted negative behaviors to occur only during other nurses' shifts and not on their own working hours. Participants tended to think that aggressive patients should not be hospitalized because they could cause problems in the ward. They also believed that it was natural to apply restraints longer than recommended on such patients, as reflected by one nurse who said, “Why do I care for this patient? I think that if the patient is compelled to suffer, it is a deserved result and a correct treatment.” Some participants displayed immoralism by not reporting mistakes or errors made in their nursing care, such as prescribing medications without the
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doctor's consent, having knowledge of doctors' malpractice, or being aggressive with the patient. Similarly, they claimed that they did not speak frankly about fellow nurses' malpractice, failed to comply with aseptic technique practices, and did not report mistakes or errors in medication. Some participants would record that a patient's condition had been identified, even if it had not. Some participants gave placebo treatments without a doctor's permission, administered a digestive to a patient requiring sleeping pills, ignored PRN (PRN is a shortened form of the Latin phrase pro re nata) orders, or gave normal saline to a patient requiring a painkiller, all without doctor's consent. In some cases, after a patient suicide or disappearance, participants were willing to accept a doctor's suggestion of fabricating the patient's chart. Moral Complacency Some participants showed moral complacency with regard to the compulsory treatments applied to the psychiatric patient and PRN orders. Participants considered medication as the best policy, regardless of the patient's autonomy, in order to improve the patient's symptoms. Some participants thought that compulsory restraints were the best treatment for patients who were more likely to bring harm to themselves or others. Others stuck to their own perceptions of the patient's condition, such as in the example of PRN administration of sleeping pills given above. Some participants also assumed that patients who wandered at night should be administered sleeping pills. Conversely, some of the nurses thought that administering sleeping pills might contribute to a patient's addiction, so they did not give them even if the patient's condition did require them. Moral Conflict The participants experienced four types of moral disagreements, including moral disagreements against hospital administrative policies, doctors, colleagues, patients, and patients' significant others. Moral disagreements between hospital administrative policies and nurses occurred because of hospitals preferring their own interests to improve patient rights (e.g., addressing shortage of nursing staff, old facilities, and using the benefits of prolonged hospitalization). Moral disagreements between doctors and nurses occurred when the doctors inconsistently applied restraints and seclu-
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sion. Doctors' orders were also inconsistent among doctors in the same situation. Moral disagreements between nurses occurred when nurses working together had different strategies for managing their patients' symptoms. For example, one nurse accepted all of a patient's repeated requests, whereas the other nurse did not. Disagreements arose between nurses and a patient's significant other when a patient was discharged by his or her family despite needing further treatment, when the patient's significant other hospitalized a patient who was not a danger to self or others, or when a patient's significant other did not discharge the patient once his or her condition had improved. Participants had moral dilemmas in situations in which the patient's significant other began the admission procedure and ignored the patient's autonomy or when the doctors made a unilateral decision about whether the patient was allowed to make a telephone call, have visitors, or take a walk. Such dilemmas also occurred when doctors decided they should apply restraints and seclusion or prohibited sexual behaviors such as kissing, intimate touching, exposure, and intercourse between patients without considering patients' autonomy. Moreover, participants had moral dilemmas regarding the use of compulsory restrictions as a way to resolve a dangerous situation or invasions of human rights and privacy. For example, although they should monitor all patients in the seclusion rooms with closed-circuit TV monitoring screens, they experienced moral dilemmas about the fact that they violated these patients' privacy, especially when patients changed their sanitary napkins or used the toilet. Participants also had dilemmas about controlling patients' sexual problems and whether medical staff should make decisions about controlling patients' natural sexual feelings. They also experienced moral dilemmas about how to maintain safe environments for patients when using toilets without a door handle and shower rooms made of transparent glass without violating patients' privacy and human rights. Moral Stress Participants experienced moral stresses such as powerlessness, frustration, guilt, and agony when confronting the moral disagreements and dilemmas presented above. In particular, they felt frustration
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when being required to unconditionally accept decisions made by patients' significant others or doctors. One participant said, “I felt powerless to see that patients' families transfer patients whose condition did not require them to be admitted to another psychiatric hospital, instead of discharging them.” Participants sometimes experience agony when applying compulsory restrictions to patients who refuse their treatment and feel guilty when watching these patients complain of pain during the restraint period. One participant described this stressful feeling of ambivalence: “I explain the necessity of the restraint to the patients while questioning the necessity of the restraint in my mind.” DISCUSSION
From the results of this study, we found that moral unpreparedness and blindness and moral numbness led to immoral behaviors, whereas unresolved moral conflicts often caused moral stress for psychiatric nurses. Nurses who had just started their careers or had limited knowledge of psychiatric nursing care experienced the highest incidence of moral unpreparedness and moral blindness. In particular, because new nurses were not confident about their own moral judgment, they experienced confusion and ultimately followed the views of senior nurses (Park, 2004). This finding is consistent with the fact that a nurse's status and career are connected with the decision-making and coping methods employed in the face of moral issues (Ahn, Kim, Cho, Um, & Lee, 2004); the more experienced a nurse is, the more knowledge he or she has regarding moral issues. It is necessary to educate new nurses about the ethics of psychiatric nursing and coping methods for the moral issues they will encounter. Furthermore, more experienced psychiatric nurses should share their knowledge, skills, and experiences with new nurses to help them further develop their moral decision-making skills. This study shows that concepts, such as moral indifference and moral complacency, reflect the unique ethical problems in psychiatry. Participants showed moral indifference toward patients with chronic mental illnesses, especially those who had been hospitalized for long periods. This is in line with current research, which found that psychiatric staff members are more likely to think that they do not respect the autonomy and rights of patients
with severe symptoms, if those patients were hospitalized long term (Ohnishi et al., 2010). After Korea enacted the Mental Health Act in 1995, it has strived to conduct deinstitutionalization, but the actual duration of hospitalization in psychiatric hospitals was an average of 245 days (Lee, Oh, & Park, 2008), compared with a week in the United States and 11 weeks in the United Kingdom (The Japan Times, 2011). Long-term hospitalization is thus a national issue that requires systematic improvement. We suggest the establishment of more specific resolutions, including creating a workplace rotation system or an off-day system, that will provide nurses with time to reflect their own nursing practice and thus enhance their potential for ethical practice. Moral numbness, if left unresolved, can cause serious problems, resulting in moral or legal disputes with patients and their families. Some participants in this study showed immoral behaviors, due primarily to a lack of early efforts to correct their numbed sense of morality. Immoral behaviors that are not corrected during a nurse's early career tend to get worse as time passes, so education programs to correct these behaviors are urgently needed, especially for new nurses. Worse yet, these nurses may not know that such behaviors constitute immoralism. Thus, psychiatric nurses require rigorous training to ensure that they do not overlook even trivial moral problems in order to prevent future immoral behaviors. Although the current nursing curriculum in Korea includes education for legally and ethically desirable nursing standards and practice, it must also include teaching of other significant, yet still underaddressed, issues such as moral unpreparedness and moral numbness. If these issues are left untreated, it will result in moral indifference, followed by various further moral problems. Cooperation with colleagues and employing institutions are important for nurses, but they can sometimes cause conflicts with their responsibility as an advocate of the patient's rights (Fry & Johnstone, 2002). Psychiatric nurses in this study felt conflicted about moral disagreements and reluctantly complied with hospital policies and doctor's directives, even when they realized that such directives were unjust. Although nurses have excellent judgments and abilities, they assume an attitude of passive conformity according to the traditional cultural norms of their job (Meyers,
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2002). When nurses ignore their own moral judgments in favor of a doctor's authority, hospital policies, or legal restrictions, they often experience psychological pain and discomfort (Kälvemark, Höglund, Hansson, Westerholm, & Arnetz, 2004). Neglecting moral disagreements causes even greater moral stress. Moral conflicts were the most common problem faced by the participants in this study. The most difficult moral conflicts represented in this study included restraints and isolation, compulsory admission and discharge, and privacy violation. The compulsory admission rate of Korean mental health facilities is 87% (Kwon, 2010), although compulsory treatment has not been identified in current statistics (Cho, 2005). Patients with psychiatric illness do not have self-determination, their privacy is not protected, and they experience serious human rights violations. Because psychiatric moral conflicts are mainly caused by compulsory treatments, other methods are being studied as possible ways to control the behaviors of aggressive psychiatric patients (Gaskin et al., 2007), but there are currently few options outside compulsory treatment (Foster, Bowers, & Nijman, 2007). It is likely that there will be alternatives to reduce moral conflicts, allowing psychiatric nurses to create clear guidelines and regulations and establish a therapeutic environment that respects their patients' human rights (Kontio et al., 2010). Similarly, psychiatric nurses need emotional support so that they do not feel guilty about compulsory treatment. Moral stress manifests as physical symptoms, such as fatigue and sleep deprivation, and as psychological symptoms, such as feelings of helplessness, guilt, and remorse. These moral stresses eventually trigger burnout (Ohnishi et al., 2010). Participants in our study did not overcome moral conflicts, instead they reported feelings of depression and high hospital turnover. A study related to moral stress reported that nurses did not overcome their stress and, instead, resigned from their jobs (Corley, Elswick, Gorman, & Clor, 2001). In another study, nurses who perceived intense moral distress reported feeling unsafe in their workplace (Pauly, Varcoe, Storch, & Newton, 2009). Thus, it is necessary for nurses to relieve their distress through professional help such as counseling and vacation. However, there is currently nowhere for psychiatric nurses to discuss moral stress professionally (Cho, 2005), and nurses
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who failed overcome their stressful situations changed jobs. Support systems must be incorporated into institutional systems to prevent and relieve psychiatric nurses' moral stress. CONCLUSION
This study described the ethical problems experienced by psychiatric nurses working in psychiatric facilities in Korea. Psychiatric nurses experienced the most moral problems in situations of applying compulsory treatments or when violating the psychiatric patients' human rights and autonomy. Participants in this study experienced a conflict between playing the role of a patient advocate and the role of a doctor's assistant. They experienced moral stress because they felt that they should respect the patients' human rights and autonomy but were unable to do so. We must find various ways to maintain patients' human rights and autonomy in order for the psychiatric nurses to be able to support them. The findings in this study suggest some implications for nursing practice, research, education, and administration. First, changes must be made in nursing practice to provide accurate and consistent moral guidelines about diverse moral problems in the field of nursing. In addition, a cooperative system and a culture of good communication must be established between psychiatrists and psychiatric nurses in order to enhance the patients' welfare and reduce psychiatric nurses' moral difficulties. Researchers must explore psychiatric nurses' moral decision-making processes, which will provide a theoretical basis for improving nurses' moral behavior. Researchers must also examine differences between the moral experiences of psychiatric nurses and those of other clinical nurses. Such comparative analyses will identify moral problems specific to psychiatric nurses and, thus, help develop programs appropriate for them. Hospitals need to provide psychiatric nurses with educational programs that help them make the best ethical decisions in complex clinical situations. The programs should be prepared and developed in conjunction with legal and medical experts in order to provide the most effective approaches to the legal and moral problems of nursing. Hospitals should also provide professional counseling for psychiatric nurses to ventilate their moral stress. Furthermore, in an effort to prevent the moral disagreements that
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