I Deont(ological) Care!

: Exploring the Principles of Deontology in Critical Care

Nursing

Introduction

Critical care nursing is a specialized field within the nursing profession that focuses
on providing comprehensive and intensive care to critically ill patients. The importance of
critical care nursing cannot be overstated, as it directly impacts patient outcomes and survival
rates. In recent years, there have been significant advancements in critical care nursing that
have revolutionized the way patients are cared for. Among these advancements include
incorporating ethical frameworks. According to Mallari and Tariman (2016), ethics is the
foundation of nursing. Historically speaking, the practice of nursing is concerned with
tending to the needs of the sick which requires sound judgment and decision-making to
improve the welfare of these sick people (Mallari and Tariman, 2016). As much as it is
significant, ethical frameworks in critical care nursing are multifaceted, as nurses are often
faced with difficult decisions concerning decision-making, like cases in end-of-life decisions
and refusal of treatments. In this paper, my primary focus is to explore the application of
deontology, a moral theory that emphasizes the importance of duty and moral rules, to critical
care nursing. In section A, I will first define what deontology is and its principles. By
examining the principles of deontology, we can gain a deeper understanding of how this
ethical framework can guide nurses in their decision-making process. Then, in section B, I
will narrate a critical care nursing scenario and attempt to apply how the principles of
deontology provide insights into such a scenario. In section C, I will conclude how ethical
frameworks such as deontology can further improve the practices of critical care nursing.

A. Understanding Deontology

Understanding deontology is better when compared to its counterpart,

consequentialism. Consequentialists claim that the outcomes of an action determine whether
a person adheres to moral or immoral ideals. In contrast, deontology is a moral theory that
focuses on the intention of actions themselves, rather than the consequences or outcomes of
those actions (Alexander and Moore, 2021). Also known as deontological ethics, it derives its

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name from the Greek words "deon," meaning duty, and "logos," denoting science or study.
When put together, deontology asserts that individuals have certain obligations, duties, or
moral rules that they must adhere to, regardless of the outcome. This ethical framework sets a
specific set of principles and moral guidelines to determine whether an action is right or
wrong, without considering the potential consequences (Barrow and Khandhar, 2023).

One of the core principles of deontology is the categorical imperative, which was
introduced by Immanuel Kant, a prominent figure in the realm of deontological ethics. The
categorical imperative states that individuals should act based on moral rules that can be
universally applied (Johnson and Cureton, 2022). In other words, if an action is considered
moral for one person, it should be considered moral for anyone facing a similar situation.
This principle aims to establish a sense of fairness and consistency in ethical decision-making
and prevents individuals from making exceptions or treating themselves differently from
others.
Furthermore, deontology focuses on the intrinsic value of individuals and their
autonomy. According to this moral theory, individuals have inherent worth and should be
treated with respect and dignity, regardless of any external factors such as their characteristics
or status in society. Therefore, deontologists believe in the importance of respecting the rights
and autonomy of others, as well as promoting justice and fairness in interpersonal
relationships. Deontology also distinguishes between two types of duties: categorical
imperatives and hypothetical imperatives. Categorical imperatives or perfect duties are those
that must be followed at all times and in all circumstances, whereas hypothetical imperatives
or imperfect duties allow for more flexibility and discretion in their fulfillment (McCartney
and Parent, 2021). An example of a perfect duty might be not to kill, whereas an imperfect
duty might be to help others in need whenever possible. This distinction recognizes that
moral obligations can differ in their level of severity and provides some guidance in
prioritizing and balancing between different duties.
While deontology offers a solid framework for making moral decisions, it is not
without criticism. One potential drawback is the inability to account for the consequences or
outcomes of actions. Critics argue that focusing solely on duty can lead to morally
questionable decisions if the results are ignored (Alexander and Moore, 2021). For instance,
if telling a white lie could save someone's life, deontology would deem it morally wrong
because it violates the duty not to lie, regardless of the positive outcome.

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 Moreover, deontology can sometimes lead to conflicting duties. The rigid adherence
to principles without considering the context or conflicting obligations can create moral
dilemmas. For instance, if the duty to honesty conflicts with the duty to protect someone's
well-being, deontology does not provide clear guidance on how to resolve the conflict or
prioritize one duty over the other conclusion, deontology is an ethical framework that centers
around the moral duties and obligations individuals have. It emphasizes the importance of
following universal moral rules and treating others with respect and dignity. While it provides
clarity and consistency in ethical decision-making, deontology struggles to address the
consequences of actions and can sometimes lead to conflicting duties. Nonetheless,
deontology plays a significant role in shaping our moral judgments and understanding our
responsibilities towards others.

B. Illustrating the Intersection of Critical Care Nursing and Deontology

In this section, let us consider this scenario from Marsh (2023, p. 21): Having worked
in the ICU for five months, a novice nurse was assigned to a 20-year-old patient with acute
respiratory distress syndrome (ARDS) and pneumonia. Before he was transferred to the ward,
a chest tube was inserted into the patient because of his pneumothorax and the doctors
planned for a CT scan of his lungs. When the doctor asked the nurses to prepare the patient
for the CT scan, the nurse prepared everything and asked the senior nurse to recheck her
preparation. However, after the senior nurse exited the room, the novice nurse sealed the
chest tube bottle because she claimed that such an action was a protocol she learned
somewhere. The patient started to desaturate (spo2 from 97% to 80%), tachycardic (HR
120/min), and hypotensive (BP 83/60mmhg) after 15 minutes of his chest tube clamping.
Eventually, the patient had a weak pulse rate, and a code blue was announced. During CPR,
the doctors learned that the clamped chest tube caused the patient's heart to decline. By
clamping the chest tube, the air accumulated in the lungs compressed the heart. After
unclamping the chest tube and 5 minutes of resuscitation, the patient was revived. The
doctors were annoyed by the fact that the nurse’s action could have led to the death of their
patient who was on the road to stability.

Again, critical care nursing requires highly skilled and knowledgeable nurses who can
effectively manage complex medical conditions, monitor vital signs, administer medications,
and provide emotional support to patients and their families. By adhering to deontological

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principles, critical care nurses should ideally prioritize the inherent worth and dignity of each
patient, recognizing their autonomy and right to make decisions about their care. This ethical
approach ensures that patients are treated with respect and that their wishes are honored to the
best extent possible.

Of course, mistakes sometimes arise in professional settings, especially when people

are not yet accustomed to the proper procedures and protocols. But take note that in cases that
require extra caution, a minor miscalculation can result in major casualties. Like the scenario
above, one minor misjudgment and decision can lead to fatal loss or damage to people which
is the one thing that people in critical care nursing should avoid.

In the scenario above, not only consequentialists, but also deontologists will identify
that the novice nurse committed a mistake, in intent and outcome. In the first half of the
scenario, I can say that the novice nurse is adhering to her duties as one who provides care for
the patient and helps the doctor in preparation for his CT scans. But the moment the novice
nurse clamped the chest tube, she had failed to carry out her categorical imperative. As part
of her duty to provide care for her patient, she did not look into the best interests of her
patient. Instead, she did such an action because she recalled from her memory that clamping
the chest tube was a protocol. She may have done such because either she did not want her
superiors mad at her or she wanted to be praised for taking initiative. Regardless, when
viewed from a deontological perspective, her intentions were immoral.

In addition, the principles of deontology also involve full disclosure of information to

patients which includes good and bad news regarding the patient’s health (Barrow and
Khandhar, 2023). Though it was not mentioned in the scenario, the doctors and the nurses
should report to the patient what went wrong. I recognize that disclosing information is easier
said than done because of shame, lack of communicative skills, and fear of litigation. But if
the aim is to provide better care for patients, sharing errors and apologizing for errors should
be done to promote justice and fairness between the medical workers and the patients.

Deontology also acknowledges the importance of non-maleficence, which requires

critical care nurses to not harm their patients. This duty involves carefully considering the
potential risks and benefits of interventions and treatments, and ensuring that the benefits
outweigh the potential harm. As observed from the scenario, the novice nurse might not have
intended to harm the 20-year-old patient, but she did not weigh what her action of clamping

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the chest tube entailed. By lacking judgment, the nurse endangered the life of the patient
which is a big no-no for her duty.

Aside from what has been observed from the scenario, there are more illustrations of
how deontology intersects with critical care nursing. Deontology underscores the duty of
beneficence, which compels critical care nurses to act in the best interest of their patients.
This duty includes providing competent and compassionate care, advocating for the patient's
needs, and ensuring their safety and well-being. Critical care nurses must constantly strive to
improve their knowledge and skills to fulfill this duty effectively.

In challenging situations where conflicting ethical principles arise, critical care nurses
must engage in ethical deliberation and seek guidance from ethical committees or colleagues.
This collaborative approach can help ensure that decisions are made in the best interest of the
patient while upholding the principles of deontology. This approach can be considered as the
intersection of critical care nursing and the principles of deontology.

C. Advancing with Deontology

This paper has explored the application of deontology. Section A of the paper
provided a discussion on the principles of deontology such as the categorical imperative and
the focus on intrinsic human value and autonomy. Section B illustrated the intersection of
deontology with critical care nursing through a scenario involving a novice nurse's critical
mistake. The analysis from a deontological perspective highlights the nurse's failure to adhere
to her duty, emphasizing the principles of beneficence, non-maleficence, and the importance
of full disclosure to patients. In sum, there is a need for critical care nurses to uphold
deontological principles, such as beneficence and non-maleficence, in challenging situations.
Ethical deliberation and collaboration are recommended to navigate conflicting ethical
principles, ensuring decisions align with deontological principles and are in the best interest
of the patient. Furthermore, critical care nursing will improve as it continues to be informed
by the principles of ethical frameworks such as deontology. As long as the field of medicine
opens its doors to approaches and principles from other disciplines such as ethics, the primary
objective of nursing to provide care will be effectively and efficiently achieved.

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References:

Alexander, L. and Moore, M. (2021). Deontological ethics. The Stanford Encyclopedia of

Philosophy (Winter 2021 Edition), Edward N. Zalta (ed.).
https://plato.stanford.edu/entries/ethics-deontological/#PatCenDeoThe.

Barrow, J.M. and Khandhar, P.B. (2023). Deontology. StatPearls [Internet].

https://www.ncbi.nlm.nih.gov/books/NBK459296/.

Johnson, R. and Cureton, A. (2022). Kant’s moral philosophy. The Stanford Encyclopedia of
Philosophy (Fall 2022 Edition), Edward N. Zalta & Uri Nodelman (eds.).
https://plato.stanford.edu/archives/fall2022/entries/kant-moral/.

Mallari, M.G. & Tariman, J.D. (2016). Ethical frameworks for decision-making in nursing
practice and research: An integrative review. Via Sapientiae.
https://via.library.depaul.edu/cgi/viewcontent.cgi?
referer=&httpsredir=1&article=1000&context=son-research-synthesis.

Marsh, R. (2023). Critical care nursing. American Journal of Nursing, 123 (10): 21.

McCartney, S. and Parent, R. (2021). Deontology. Ethics in Law Enforcement

https://opentextbc.ca/ethicsinlawenforcement/chapter/deontology/.