Ethical Dilemma in Nursing Students: A Case Study

Abstract

Aim: The aim of this study was to get the opinions of nursing students about the issues that they may be ethically dilemma in during the decision-making process. Methods: In this study, the case study method, one of the qualitative research methods, was used. Nursing students' debates about the topics of organ donation, euthanasia, abortion, and refusing treatment subjects were recorded by the researchers of the study and transcribed later. This study was carried out with 42 nursing students studying in the third year of a public university. This study group was selected by convenience sampling method Results: When the results of the study were examined, it was reported that nursing students had diverse ideas ethically on organ donation, euthanasia, abortion, and refusing treatment subjects. Conclusion: It was observed that students took a certain attitude about the topics they determined in their discussions on issues that might create an ethical dilemma, they tried to persuade others by respecting their rights and expressed themselves within the framework of the ethics lesson they took.

Headnote

Abstract

Aim: The aim of this study was to get the opinions of nursing students about the issues that they may be ethically dilemma in during the decision-making process.

Methods: In this study, the case study method, one of the qualitative research methods, was used. Nursing students' debates about the topics of organ donation, euthanasia, abortion, and refusing treatment subjects were recorded by the researchers of the study and transcribed later. This study was carried out with 42 nursing students studying in the third year of a public university. This study group was selected by convenience sampling method

Results: When the results of the study were examined, it was reported that nursing students had diverse ideas ethically on organ donation, euthanasia, abortion, and refusing treatment subjects.

Conclusion: It was observed that students took a certain attitude about the topics they determined in their discussions on issues that might create an ethical dilemma, they tried to persuade others by respecting their rights and expressed themselves within the framework of the ethics lesson they took.

Keywords: Nursing students, ethical dilemma, organ donation, euthanasia, abortion, refusing treatment

Introduction

Currently, developments in science and technology have raised the value problems and increased the importance of ethics in health as well as in all fields (Kang, 2017). As the boundaries of health services expand continuously, health ethics is constantly challenging and developing (Park, Kjervik, Crandell, & Oermann, 2012). Nurses, which are part of the health care system, have to make more complex decisions and take responsibility of these decisions due to their expanding roles and functions (Safa & Hajbagheri, 2019).

Nurses face many ethical problems and dilemmas arising from patient relatives, work team or health policies while fulfilling their duty responsibilities (Ahn & Yeom, 2014). These problems are generally ethical issues such as disagreements with other members of the team or the institution about patient care and treatment, protection of patient rights, care of the patient in the terminal period, obtaining consent, sharing limited resources, and having unethical attitudes of colleagues (Safa & Hajbagheri, 2019). In such cases, nurses may have conflicts between the values and expectations of the patient and their own values and judgments. In this case of an ethical dilemma, the nurse should be able to make the right ethical decision (Rainer, Schneider & Lorenz, 2018).

According to Fry (1991), the ethical dilemma results from the confusion between the two values in a situation that needs to be decided during an action. In other words, nurses encounter two or more options in case of a situation to decide, but when she cannot decide which option is better or cannot solve the problem with the options they have , they are faced with an ethical dilemma (Craven & Hirnle 1996). In such cases, the correct answers are unclear and there are no strict rules to solve the dilemmas (Sauerland, Marotta, Peinemann, Berndt, & Robichaux, 2014). Ethical decision making is an integral part of nursing responsibility and one of the main objectives of nursing education for nurses who encounter such situations throughout their working life (Khatiban, Falahan, Amini, Farahanchi, & Soltanian, 2019).

Professional ethics education has become more and more important in nursing education in recent years. Nursing ethics education contributes to the development of the ability of nursing students to identify and solve ethical problems by providing the opportunity to develop critical thinking and moral reasoning skills (Albert, Younas, & Sana, 2020; Khatiban et al., 2019; Rainer, Schneider & Lorenz, 2018).

The method of teaching nursing ethics is as important as the teaching of nursing ethics. It was emphasized that the method of teaching is very effective on acquiring new information by the student (Y eom, Ahn, & Kim, 2017). Lecturing as a traditional teaching method has been widely accepted by educators and students, especially in undergraduate nursing education (Kim, & Park, 2019). Though teaching only through lecturing is easy method for tutorials (Zhang, Zhang, Stafford, & Zhang, 2019), it is insufficient for students' comprehension of some concepts and effective learning (Day-Black, 2015). In order to provide effective learning, alternative methods should be replaced by traditional ones (Yeom et al., 2017). Various teaching methods are required to improve the knowledge and comprehensive skills of nursing students who will benefit most from health services in current nursing ethics education (Alba, 2018; Simsek, Senturk, & Akca, 2017).

Consequently, discussing ethical dilemmas through discussions in the lecture environment would both help students better understand the concept of ethics and help students make faster and more accurate decisions in the face of ethical dilemmas that nursing students may encounter performing their duties. The aim of this study was to get the opinions of nursing students about the issues that they may be ethically dilemma in during the decision-making process.

Method

Study Design: In this study, case study method, one of the qualitative research methods, was used. In phenomenological studies, it is attempted to form the essence of the participants' experiences about events, situations or concepts (Creswell, 2013).

Participants: This study was carried out with third grade nursing students in professional ethics course. 42 students attending a public university participated in the study. This study group was selected by convenience sampling method.

Implementation: Prior to the study, all students who agreed to participate were informed about the current study and their written and verbal consent was obtained. All students voluntarily agreed to participate in the study. Professional ethics course lasts 14 weeks in the spring semester. In this course, ethical concepts and principles, concepts of law, ethics and deontology, values, law and regulations, the concept of ethics in nursing and ethical dilemma, ethical codes in nursing, human rights, malpractice, ethics and plagiarism in scientific researches were covered. At the tenth week of the semester, all students were asked to form groups of 5 or 6 people to be determined by themselves. Each group was asked to choose a topic that they chose voluntarily, and which is still ethically discussed. The identified groups of students voluntarily identified six topics which are organ donation, euthanasia, abortion and refusing treatment. However, the subject titled HIV positive women pregnancy was excluded from the study due to insufficient data. The students were asked to be divided into two separate groups within the group and to discuss their own topic as ethical or unethical. Which side of the discussion that students support was left to the students' choice. The course lasts 2 hours per week and two topics were discussed in each course. Each discussion lasted one hour, and each topic was discussed by the students in front of the whole class. The discussion was followed by two researchers and there was no intervention and guidance during the discussions by the researchers, but they were the only moderators of time management and deviating from the discussion topic. The other students in the class only participated in asking questions. They did not comment on the discussion. The discussion of ethical issues was recorded and then the data were transcribed by the researchers. The related data were presented in two tables, ethical and unethical.

Data Analysis: Nursing students' debate about the topics of organ donation, euthanasia, abortion and refusing treatment subjects were recorded by the researchers of the study and transcribed later. The students' prominent ideas about the discussion topics were presented in the related tables as to why they find the discussed topic ethical and why not.

Ethical Aspects of Research: Ethics committee approval was obtained from the Ethics Committee to conduct the research. Written and verbal consents were obtained from each student participating in the study.

Results and Discussion

In this study, nursing students were asked to identify some issues with ethical dilemmas within the scope of ethics course and to discuss the ethical and non-ethical aspects of these issues in the classroom environment. Students identified five subjects which are organ donation, euthanasia, abortion and refusing treatment that may arise ethical dilemmas in their professional life. This section includes students' opinions on these issues.

Organ donation is the donation of some or all of a person's organs, while still healthy, for use in other people after brain death. Some students favored organ donation as ethical claimed generally organ donation from animals or humans to restore one's health or ease one's pain/suffering. On the other hand, organ transfer has not been found to be ethical on grounds that it prepares the ground for organ traffic, disrupts the integrity of the person, puts pressure on the relatives of the person who will take the organ, and the transfer from animal to human disrupts the psychology of the person. Below you will find some excerpts from group discussions on organ donation.

"People who have come to the end of their lives, have lost their hopes for life, and live in great suffering, can get rid of their pain and continue their lives thanks to organ transplants. The number of patients who are trying to live their lives connected to dialysis machines or waiting for organ transplants is increasing day by day. This situation seriously increases the burden of the person on himself, his/her family, and the state. Thanks to organ donation, these people get rid of their pain, their maintenance costs are reduced, and they become producers when they are in a consumer state due to their illness. "

"Organ donation can be made from animal to human because human beings have always needed animals to survive since the creation of the world. Most of the drugs we use even today are obtained using animals. In addition, before considering the dignity of a person, it should be aimed to keep him/her alive. For these reasons, if there is no other remedy for treatment and human donors cannot be found, organ donation from animal to human should be made possible under medical supervision. "

"In accordance with the ethical rules regarding organ and tissue donation, it is necessary for physicians to obtain their consent by informing the recipient and donor, to investigate the suitability of donation for both parties and to save only life without profit. Today, some physicians commit crimes by acting against the medical ethics by mediating organ trafficking. "

"Organ and tissue donation from the animal, which is legally prohibited in our country, is not permissible in terms of Islam, as can be understood from the statement of the Religious Affairs Directorate. Animal donation is indeed a controversial issue in terms of ethics, and these transplants are thought to harm human dignity. "

"Organ and tissue donation have a moral dimension to the extent that it is associated with the concept of donation. Examining the moral dimension of the subject, Kant opposes organ and tissue donation on the grounds that nobody can give up their body parts even if they want to, and that they cannot harm their own body. Thus, s/he does not support voluntary donation. Kant said that her/his opinion on this matter was that a person 's body integrity should not be disrupted in any way (by the physical intervention of people outside) and he was determined to do so. "

"There are some advantages and disadvantages to the person to whom the transplant is made. The existence of cultural differences provides a disadvantage in this case. For example, close relatives/patient relatives of people who need organ donation are compelled by the society and are forced to donate their organs even though they do not want to donate their organs. This situation may cause serious problems for the person who donates organ in terms of health in the future. In other words, the person who donated organs becomes a sick person. If a person who donates one organ loses the remaining organ and no organ is available, this can lead him to death. "

"When it comes to the vital situation of a person with high social status, other patients (those who are in vegetable life, etc.) can end their organs and take their organs in an illegitimate way. The heart valves of pigs can be transferred to some unconscious patients with the decision and permission of the family. Later, after the patient, who has regained consciousness, has learned this situation, he may experience psychological traumas and this situation can go to suicide, if the organ to be transplanted is a penis or vagina, then the patient thinks that these organs do not belong to him and likewise cause psychological traumas".

Organ transplantation is truly one of the miracles of modern medicine, it saves the lives of many patients and improves the quality of life. Given the growing gap between the number of organs needed and the supply, clinicians have an ethical obligation to ensure that those who wish to donate organs are respected (Truog, 2008). According to Delmonico, Arnold, and Youngner (2002), a market organ donation system promotes class separations (and exploitation), violates the inalienable values of life and freedom and is therefore not ethically acceptable. On the contrary, the non-monetary recognition of donations refers to our equity concepts and, most importantly, does not destroy the altruistic social benefit that needs to be preserved in a revised organ donation system. Organ donation is essentially an altruistic gift for the benefit of others, it may involve some risk or harm to the patient or family, in which case clinicians have an obligation to support patients' wishes (Truog, 2008). Many patients with end-stage organ failure no longer rely solely on the waiting list. Instead, they turn to spouses, friends, or suffocates as possible donors-a medically acceptable alternative, because advances in immunosuppression have eliminated the need for a genetic match for successful organ transplantation (Delmonico, Arnold, & Youngner, 2002). But sometimes, high organ demand led to commodification, mostly in countries with weak regulatory authorities and a large part of the population below the poverty line (Shroff, 2009). Spain is the leader in organ donation despite all ethical controversies. It has been deemed unethical in the UK, especially for individuals with severe brain injury to be admitted to nontherapeutic intensive care and connected to a ventilator. However, it was later declared ethical by the National Institute for Health and Care Excellence (Martín-Delgado et al., 2019). Organ transplants are performed in many developing countries; however, the rate of organ donation is low in some Islamic countries except Turkey on the grounds of religious beliefs (Tumin et al., 2016).

Euthanasia is another issue in which ethical dilemmas may occur in the field of health. In the current study, while some nursing students stated that the doctors' duties are not only to heal or reduce pain, but also to ensure easy and fair death, some of them generally did not find euthanasia ethical on the grounds that it was religiously against the sanctity of life. They also believed that life is too valuable to be indispensable must be absolutely protected against any kind of intervention. Below you will find excerpts from nursing students' statements about euthanasia during group discussion.

"In a statement made by Francis Bacon in 1623, he argued that his task was to help the patient regain his health, as well as to relieve the patient's pain. He argued that the task of relieving the pain of the doctor exists not only when the disease will heal, but also when it provides an easy and fair death. "

"In his 1889 book Moral Für Arzte, Nietzsche defended euthanasia by saying, "It is no longer appropriate to live in a certain situation anymore ". "

"In European law, euthanasia is legal in the Netherlands, Belgium and Luxembourg. It is legal in Canada and California in some states of the United States. In a case brought to court in 1984 in the Netherlands, the doctor gave a high dose of Morphine to the death of the patient, since a 95year-old hip, deaf and blind patient wanted to end his life persistently. In this case, which was referred to the Supreme Court of the Netherlands, the court accepted the doctor without guilt, saying, "Among the duties of a conscientious physician, his preference is to use death ". "

"Euthanasia should not be legal because the sanctity of life should be the first place for doctors. The right to life is not a legal right that the person has and can freely decide on. "

"The right to live legally is the most fundamental legal value that makes human beings human. Therefore, it must be absolutely protected against attacks from others. The person has no right to demand the end of his life from someone else. "

"If we examine from a religious perspective, the owner of the right to life is the god, and the god takes the life he gives himself. God decides when life will end in Jews, Christians and Islam, and choosing death is against God's will, the person has no right to die. In Christianity, life is considered to be the gift of God, and suffering, especially in the last moments of life, has a special place in sharing man's patience. Therefore, there is no place for euthanasia in Jewish, Christian and Islamic religions. There is no right to end a person's life in Islam. It is considered murder if any person on his deathbed is killed even at his own will. The example in Islam is that Hazrat Eyüp, who fell into bed, returned patiently to the new life despite the infection of the whole body and getting rid of it. "

"According to the Euthanasia Declaration adopted by the World Medical Association in Madrid in 1987, "euthanasia, which means ending a patient's life, even with his or her relatives' permission, is unethical". "

"If anyone causes his death with the consent of the victim, he is sentenced to 6 to 15 years' imprisonment. The termination of care by the physician from Germany, Austria, Switzerland and Norway is to allow abuse, killing and death, this is a crime. "

"Legally, human life is too valuable to be indispensable and must be absolutely protected against any kind of intervention, life is untouchable. "

"Failure to cure the patient is extremely difficult with the rapid development of medicine. Diseases that were once untreated are now quite simple to treat. "

"The sick individual is experiencing a physical and mental collapse, in fact, the person seeking euthanasia does not have a criminal capacity. "

As stated by Keown (1997, p.23), the Dutch medical profession and civil authorities define euthanasia as follows: "killing at the request of the person killed". He called it voluntary euthanasia, and distinguish it from non-voluntary euthanasia in which the person killed is not able to make or reject such a request, and involuntary euthanasia in which the person killed is able to make such a request but has not done so. Another term for euthanasia is slow euthanasia. In end-of-life care, this type of euthanasia may be more acceptable to patients, family members, and healthcare professionals rather than swift compassionate killing. In slow euthanasia with morphine drip, regardless of how well the patient's pain or other physical distress is controlled, the dose is gradually increased or sustained, at least to maintain drowsiness, often to produce obstruction, coma and even visible respiratory depression (Billings & Block, 1996). People living in the last stages of their lives may want to end their lives for various reasons. these are determined as follows: loss of autonomy, inability to engage in enjoyable activities, loss of dignity, loss of control of bodily functions, burden on family/friends/caregivers, and inadequate pain control (Yun et al., 2018). According to Marsala (2019), individuals belonging to more conservative religious groups and exhibiting higher religiousness are less likely to approve euthanasia. Quaghebeur, Dierckx de Casterlé, and Gastmans (2009) signified that professional nursing institutions should clarify the degree to which nurses' involvement in caring for a patient seeking euthanasia is aligned with professional ethical values and norms. Nurses facing euthanasia demands should be supported both in countries where euthanasia is legal and in countries that are not. Euthanasia for people who are not terminally ill, such as those suffering from psychiatric disorders or dementia, is legal in Belgium under strict conditions but remains a controversial practice (Dierickx, Deliens, Cohen and Chambaere, 2017). Currently, euthanasia or doctor-assisted suicide can be legally enforced in the Netherlands, Belgium, Luxembourg, Colombia and Canada. Except for euthanasia, doctor-assisted suicide is legal in 5 US states (Oregon, Washington, Montana, Vermont and California) and Switzerland. Among the causes of euthanasia, 70% cancer such as old age, severe mental illness, dementia, and pain (Emanuel, Onwuteaka-Philipsen, Urwin and Cohen, 2016). However, the public and health professionals still have serious discussions on this issue. The most important reason for the difference of opinion is the fear of exploitation of this situation (Emanuel et al., 2016; Sprung et al., (2018).

The issue of abortion is a very controversial situation not only in the country where the study was conducted but also in many countries, and when it is not done under the appropriate conditions and time, it is a situation that causes the death of many women. Since the right to life of an unborn creature will be denied, the circumstances in which abortion can be decided and its moral and legal consequences are highly controversial. The opinions of the students participating in the study on abortion are given below.

"There is not much to say about termination of pregnancy due to medical necessity. The important issue here is ethical problems in termination of pregnancy and termination process in line with the wishes of the parents. "

"Abortion cannot be used as a contraceptive method. However, what needs to be done is termination of pregnancy when an anomaly or a fetus-related disease is diagnosed. If this is not done, the woman may be exposed to bad consequences if she cannot control her fertility. "

"In cases where the child to be born is likely to have a major anomaly or when there is a possibility of bringing a disabled child to the world, we load negative situations such as a restriction, privilege, difficulty, not being able to live a normal life. At the same time, the negative effect that the thought of bringing such a child into the world will have on the psychology of the mother is another negative situation where the health of the mother can be compromised. "

"In cases where the mother is raped, pregnancy threatens the life or one of her vital organs, in the presence of a genetic disorder in the child to be born, when the woman is a victim, as a result of incest relationship, unwanted pregnancies, when the baby will cause great problems between the spouses economically and psychologically, Abortion is required due to problems in the family during pregnancy and in cases where the child to be born will create a serious health problem for the generations to follow. "

"In the opinion of the Turkish Gynecology and Obstetrics Association about the abortion debate of the ethics and law committee, the fetus who is completely separated from his mother in terms of ethical and legal life is considered as the 'person'. The fetus is not a person but a potential person. The fetus is an embryo made up of a group of cells with the potential to be a person and has no autonomy because it cannot express itself. The mother can make this decision, taking into account her own benefit and autonomy. "

"Abortion is prohibited in the U.S. as long as the health of the mother is not at stake. The legal period for the mother to have an abortion is determined as 24-28 weeks. In cases where maternal health is at risk or there is a rape, abortion is allowed to be covered by government funds. "

"Abortion has been banned in Malta. Abortion is only allowed in the case of rape in the Greek part of Cyprus. Countries such as Saudi Arabia, Israel, Argentina, Thailand allow abortion only when the health of the mother or fetus is at stake. "

"Abortion is also harmful due to the puncture in the uterus (rupture), the risk of infection, remaining parts (requiring repeat abortion), menstrual delays, infertility due to adhesion in the uterus, frequent abortion increases the risk of abortion, and excessive bleeding after abortion. "

"Even if within the legal framework, termination of pregnancy is important for the principles of autonomy, harmlessness and usefulness and justice, which are basic ethical principles. It may be contrary to social belief and culture. "

"Perspective on the principle of autonomy: The identity of the embryo as an asset with potential to live should not be taken away. "

"From the point of view of the principle of not harming and being beneficial: The mother may be harmed in an incorrect attempt during the abortion procedure. If there is no situation threatening the health of the fetus, this situation will end the life of the fetus in terms of the fetus, naturally damaging the fetus and the principle of non-harming ethics will not be applied. "

"Perspective of the principle ofjustice: The life of a living thing (individual) is taken away and every living creature has the right to live. The right to life is one of the basic human rights and abortion causes the principle of justice to be violated. "

Some nursing students thought that abortion is ethical in cases of rape, anomaly in the baby, and threats to the health of the mother and baby. While some nursing students highlighted that abortion is forbidden in some countries, they pointed out some damages of abortion such as puncture in the uterus (rupture), the risk of infection, menstrual delays and infertility due to adhesion in the uterus, death due to excessive bleeding. In addition, some of them stated that they were against abortion because it is against social belief and culture. To elaborate, abortion has not been found ethically because of the abolition of the identity of the embryo as a potentially viable entity, against the possibility of the mother being damaged during an abortion process, and as the right to life is one of the fundamental human rights and that abortion causes a violation of the principle of justice. In the study of Um (1999), women listed the main reasons for their abortion as not asking for more children, thinking that they will not be able to properly care for their existing children and families, the possibility of fetal abnormalities, getting pregnant outside marriage, early vaginal bleeding during pregnancy. The study of Cignacco (2002) indicated that midwives disagreed between the woman's right to selfdetermination and the child's right to life. It was found that this conflict caused a high level of emotional stress and then professional identity problems. Although questions about the child's right to life are generally suppressed, the ethical principle of the woman's right to selfdetermination is rationalized. Jelen (2017) pointed out that although mass attitudes towards abortion became more and more permissive over time, polarization would continue in this regard.

Refusing treatment may sound like a similar ethical plan to euthanasia but refusing a recommended treatment does not mean the person will die. Below are quotations from students' opinions about refusing treatment.

"In order for the person to refuse the prescribed treatment, the person should be adequately and understandably understood in subjects such as disease processes, treatment options, expected risks and benefits, and possible consequences of untreated. In addition, the person giving consent should be in a mental state to understand this information and to evaluate possible results. "

"The person should not face any difficulties when making his/her decision on consent. If the patient does not accept the proposed medical intervention, it should not be faced with the threat that the medical care process will be interrupted completely. The term "involuntary/forced treatment" means hospitalizing and keeping individuals there unintentionally. This practice is frequently encountered especially in patients with psychiatric disorders. The reason for forced treatment of psychiatric patients is based on their inability to provide informed consent depending on the patients' acceptance of the disease and the need for treatment. Accordingly, the rights of patients with psychiatric disorders to refuse treatment are taken into consideration, and even patients should be hospitalized reluctantly with the consent of the attorney. In the draft mental health law drafted by the Turkish Psychiatric Association, regulations on the treatment and hospitalization of patients with psychiatric disorders are included. In the discussions in the patient rights law, the principle of respect for the right and the characteristics of the person to determine his own destiny is put on one side of the scale, without even appealing to the knowledge of the patients and to make the most correct decision on his behalf. In order to participate in the decisions about the patient and to make the final decision, the features of the proposed medical intervention should be clarified about other options and possible outcomes. However, in order for the informed consent to be valid, the patient must have decision-making competence. "

"The responsibility of telling the truth becomes important whether the patient's real informed consent was obtained prior to treatment. For example, the contemporary role attributed to the oncology nurse must decide whether s/he chooses with informed consent about the treatment and care of his patient, based on this information, accepting or rejecting the proposed treatment. Treatment should not be applied when the patient refuses treatment. "

"The most important items in the Turkish Medical Association patient rights declaration "The patient's right to self-determination and free choice should be protected in the provision of health services" and "The right to informed consent or rejection, which is an expression of respect for human dignity and integrity, should be recognized as a basis for all medical practices" and the patient has the right to choose the treatment information of his doctor". "

"It provides modern nursing values, principles of nursing ethics, occupational standards and roles, as well as the reasons that provide the rights and responsibilities of the cancer patient, from the ethics of the oncology nurse. The oncology nurse should be a guide in applying 4 principles for compassionate action. The first is the principle of not acting badly, which says that every medical and nursing practice should not cause physical or psychological harm to the patient. The second is the principle of benevolence and compassion, which says that it should offer people positive assistance wherever it is needed, the third is the principle of justice, which says that each person should be treated honestly and fairly, and finally, the principle of usefulness that should be taken to provide the best possible outcome for the greatest happiness. Nevertheless, compassionate action can cause behavior and behavior that cannot be defended ethically because it triggers the patient to act like his father or mother. This should be avoided as much as possible, and respect for the autonomy of the individual should be preserved as much as possible. In order not to upset the patient, it should not be confused with compassion, to hide the information on the grounds that he may refuse the proposed treatment, to ensure that he gives approval because he suffered even though he did not request to die. "

"The right of patients with psychological disorders to refuse treatment is not taken into account. In fact, patients are reluctantly admitted to the hospital with the consent of the attorney. It interferes with their right and immunity to the patient's involuntary treatment. However, an individual with a psychological problem should have the right to refuse treatment if there is no harm to the community and family. If the person harms the people around him and the individual is not competent to make decisions, he has no right to refuse treatment. In the article 432 of the Turkish Civil Code, "For the treatment, education or rehabilitation of every adult person who constitutes a danger for the society due to mental illness, mental weakness, alcohol and drug addiction, seriously infectious diseases or stupor, otherwise it can be placed in a convenient institution or it can be detained. ". "

Some nursing students find refusing treatment ethical if the person is adequately and reasonably understood in subjects such as disease processes, treatment options, expected risks and benefits, and possible consequences of untreated, able to be in a mental state to understand this information and to evaluate possible results. On the other hand, some nursing students drew attention to that in order not to upset the patient, it should not be confused with compassion, to hide the information on the grounds that he may refuse the proposed treatment, to ensure that he gives approval because he suffered even though he did not request to die. Though some of the students thought that some of the patients with psychological disorders have the right to refuse treatment, some of them have no right to refuse treatment if they do not harm to their community and family. Various measures can be taken to "persuade" the patient to do the right thing when conflict occurs, and the expert decides that harm is important enough to override the patient's wishes. Information can be given selectively; the patient may be "threatened" or simply a decision can be made (Holm, 1997).

Ethical education, shaped by teacher-centered one-way information transfer, cannot offer students the opportunity to seriously consider the ethical behavior rationale in cases of dilemma. The ethics lesson taught in this way has a limited effect on the student who has to make an ethical decision through ethical reasoning in situations that encounter an ethical situation and require a sensitive thinking. For this reason, ethical education should not be conducted only with simple memorization and knowledge transfer teaching method. However, critical and creative thinking skills can be improved by discussing sample cases close to real cases (Alba, 2018; Simsek, Senturk, & Akca, 2017).

Considering the results of the study, the students discussed the issues mentioned above mutually. It was observed that students took a certain attitude about the topics they determined in their discussions on issues that might create an ethical dilemma, they tried to persuade others by respecting their rights and expressed themselves within the framework of the ethics lesson they took. In the study of Kim and Park (2019), the results regarding the effectiveness of the discussion method is consistent with the results of the current study. Discussion method as stated in Kim (2010) enables students to discover and understand alternative perspectives and facilitates communication and contributes to critical thinking and discussion skills.

The focus of the constructivist approach-based discussions is not to find textbook solutions to the problems, but to recognize the knowledge and the inconsistency between the new information systems to deal with a new situation (Kim, 2010). After the students were trained on ethics, they applied the above-mentioned topics to make decisions in ethical dilemma situations that are not included in the textbooks. In this way, they have reasoned by using the discussion method used in the cases of exemplary ethical dilemma, perceiving the problems related to real life situation, making comments and using the research they have made on this subject. In the literature, there are some studies showing that discussion method has positive effects on students' critical thinking, problem solving skills (Hall, 2011; Wason & Southall, 2016), and their communication skills (Hartin, Birks, Bodak, Woods, & Hitchins, 2017). In addition, it was observed that the lessons taught using the discussion method were more permanent on the memories of the students and increased the use of the information taught in the field when necessary (Kim, & Park, 2019).

Conclusions: Ethical concepts are very crucial for a profession to survive and develop. For this reason, it would be beneficial for individuals to learn the concepts of professional ethics in the most accurate way in the education period before beginning an active duty. This is also very important issue for nursing education, which is a professional group that works directly with human life. In this study, organ donation, euthanasia, abortion and refusing treatment that may cause ethical dilemmas were discussed by students in a mutual discussion. During the study, the students advocated their views within the framework of ethical codes on the subjects they believe in on the voluntary basis. They also answered the questions of class students who did not support neither side of the discussion topic.

Although some nursing students favored organ donation as ethical claimed generally organ donation from animals or humans to restore one's health or ease one's pain/suffering, some of them did not find organ transfer ethical on grounds that it prepares the ground for organ traffic, disrupts the integrity of the person, puts pressure on the relatives of the person who will take the organ, and the transfer from animal to human disrupts the psychology of the person.

Some nursing students stated that the doctors' duties are not only to heal or reduce pain, but also to ensure easy and fair death. On the other hand, some students generally did not find euthanasia ethical on the grounds that it was religiously against the sanctity of life. They also believed that life is too valuable to be indispensable must be absolutely protected against any kind of intervention.

Some nursing students thought that abortion is ethical in cases of rape, anomaly in the baby, and threats to the health of the mother and baby. Some students highlighted that abortion is forbidden in some countries and pointed out the harm of abortion. While some students emphasized that abortion is prohibited in some countries, they pointed out some damages of abortion such as puncture in the uterus (rupture), the risk of infection, menstrual delays infertility due to adhesion in the uterus, death due to excessive bleeding. In addition, some of them stated that they were against abortion because it is against social belief and culture. To elaborate, abortion has not been found ethically because of the abolition of the identity of the embryo as a potentially viable entity, against the possibility of the mother being damaged during an abortion process, and because the right to life is one of the fundamental human rights and that abortion causes a violation of the principle of justice.

Some nursing students find refusing treatment ethical if the person is adequately and reasonably understood in subjects such as disease processes, treatment options, expected risks and benefits, and possible consequences of untreated, able to be in a mental state to understand this information and to evaluate possible results. On the other hand, some nursing students drew attention to that in order not to upset the patient, it should not be confused with compassion, to hide the information on the grounds that he may refuse the proposed treatment, to ensure that he gives approval because he suffered even though he did not request to die. Though some of the students thought that some of the patients with psychological disorders have the right to refuse treatment, some of them have no right to refuse treatment if they do not harm to their community and family.

This study would contribute to the fact that a nurse who is likely to encounter ethical dilemma situations in her/his professional life can make a healthy decision within the framework of ethical codes at the solution point of the problem. Discussing issues that are open to debate, sometimes not have a single correct answer, in the context of ethical codes would undoubtedly provide awareness to pre-service nursing students.

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