Is There a Moral Guide to Solve the Whistle blower Dilemma?
If effective and well-communicated internal structures are available to ensure employees' concerns are addressed, the need for whistleblowing does not exist. However, in a less than idealistic world, the nurse needs a model on how and when to voice a concern that helps reduce the risk as much as is feasible. MacDonald (2002) provided such a guide to moral decision making. The model is outlined with slight alteration in Table 1 .
An example to exemplify this model could be the continuous violation of an advance directive for a patient who is in the terminal phases of illness, or who is unconscious and therefore unable to voice his or her choices. By choosing to remain silent, the nurse would be complicit in violating the moral dimension of the patient's autonomy asserted in the advance directive.
The interested parties would include all other health care professionals caring for the patient, the patient's surrogate decision maker, and the nurse managers responsible for the unit. By speaking up in such a situation, a nurse would be in danger of undermining the status quo of the organization and breeching loyalty to the "conspiracy of silence," and could be seen as a troublemaker.
The issues of values, benefits versus burdens, and legal cases need reflection. The values espoused through the Code of Ethics (ANA, 2001) address the autonomy of the patient as well as the responsibility of the surrogate to speak for the patient. The burdens on the patient are more obvious than those on the nurse who speaks for the patient. The preceding negative consequences (burdens) outlined for the whistleblower may seem out of proportion to the benefits of integrity. Barry Adams, RN, could be an analogous case (Fletcher, 1998), but so could other nurses who refused to violate the patient's right to self-determination. MacDonald and Ahern (1999) found that talking to a respected friend or relative about the dilemma is an effective way to cope with whistleblowing. Violating the patients' advance directives violates not only the Code of Ethics, but other legal and organizational rules. The Patient's Self Determination Act (Galambos, 1998) and policies with the organization relative to advance directives also would be violated.
Finally, the nurse needs to ask, "Am I comfortable with this decision?" MacDonald (2002) offered some questions that can help the nurse address this question. The nurse may not be "comfortable" because often situations requiring the virtue of integrity and courage are not comfortable at the time. However, it is imperative that the nurse ask the following questions to determine if, in the long term, he or she could continue in the profession while maintaining a high level of integrity. Questions could include:
If I carry out this decision, would I be comfortable telling my family about it?
Would I want my children to take my behavior as an example?
Is this decision one which a wise, informed, virtuous person would make?
Can I live with my decision?