Learning Objectives
By the end of this section, you will be able to:
- Discuss the role of ethics in clinical judgment
- Define common ethical principles
- Analyze common causes of ethical dilemmas in health care
- Describe the process of ethical decision-making
Moral philosophy, or ethics, is the discipline related to what is morally right or wrong and creates a framework that guides decisions related to ethical patient care. Nurses make life and death decisions daily, making ethics the foundation of integrity within the nursing profession. Ethical decision-making ensures the patient’s autonomy is respected and equitable and culturally competent care is provided in alignment with a patient’s beliefs and values.
The principles outlined in the Nursing Code of Ethics are the foundation that guides nurses to use clinical judgement and provide high-quality, patient-centered care. Historically, the Nursing Code of Ethics is rooted in the Hippocratic Oath, which has guided health care professionals for centuries through the use of a set of principles. In 1950, the American Nurses Association (ANA) developed the modern-day version of the Nursing Code of Ethics that has evolved with the changing needs of patients and nurses.
Clinical Judgement
The process used by nurses when making decisions, called clinical judgment, is a key attribute of professional nursing. It is based on nursing knowledge, critical thinking, and clinical reasoning, which is then used to understand and interpret information related to the delivery of care and how it affects care outcomes. The steps involved in clinical judgement help a nurse gather and analyze data to make ethical decisions. Clinical judgement and the clinical judgement measurement model are discussed in greater detail in the chapter on Professional Medical-Surgical Nursing.
A basic understanding of concepts associated with moral philosophy as well as understanding one’s role in ethical decision-making will prepare the nurse not only to articulate their ethical positions but also to develop the needed skills to make ethical decisions in alignment with their clinical judgement.
Link to Learning
The America Nurses Association (ANA) is an organization that represents the interests of the nation’s registered nurses. The ANA fosters high standards within the nursing profession by promoting a safe and ethical work environment, promoting the health and wellness of nurses, and advocating for health-care issues that affect nurses and the public to ultimately improve the quality of health care for all. The ANA Code of Ethics for Nurses with Interpretive Statements will prepare you for situations that will arise throughout your nursing career.
Although the terms “morals” and “ethics” are often used interchangeably, they are not the same. The definitions of both terms describe beliefs related to right and wrong and suggest guidelines for a potential corrective action, but there are slight differences between the two terms. A person’s or society’s idea of what is right or wrong, called morality, is usually associated with one’s behavior. The values or system of values that are considered moral by a community, called ethics, is often culturally based. Ethics focuses on a formal, systematic study of moral beliefs, whereas morality focuses on adherence of informal, personal values (Loggins, 2023).
Ethical Principles
The nursing profession requires a high degree of ethical responsibility. As health care providers, patients not only trust their nurses to make well-informed decisions to ensure quality care and optimal outcomes, but they also rely on nurses to advocate for their best interests. The ANA’s Professional Standards includes a framework of principles and guidelines for the nursing profession. Specifically, the ANA Code of Ethics provides a definitive guide to ensure that ethical standards are upheld (ANA, 2015). Ethics includes the principles of autonomy, beneficence, justice, and nonmaleficence. The core of nursing practice includes concepts such as respect, compassion, and empathy, upon which ethical principles are built. Adherence to ethical principles ensures patients receive the highest quality care while the integrity of the nursing profession is maintained.
Autonomy
The ethical principle of autonomy acknowledges that patients have the right to maintain control and to make their own decisions related to treatment and care (ANA, 2015). Autonomy is also referred to as the right to self-determination, meaning patients have the moral and legal right to determine what will be done with and to their person. By providing patients the information they need, informed decisions can be made that align with their values, beliefs, and preferences. This enables the interdisciplinary team to coordinate care in alignment with the patient’s wishes as well as promote strong relationships that ensure quality care. For example, this principle would enable the interdisciplinary team to support and respect a patient’s decision about the acceptance or refusal of life-sustaining treatments.
Beneficence
The ethical principle of beneficence relates to the nurse’s responsibility to act in their patient’s best interest; in essence, it is the duty to do good. The ANA defines this principle as “preventing harm, removing harmful conditions, or affirmatively acting to benefit another or others” (ANA, 2015, p. 41), and it emphasizes the promotion of the patient’s well-being and interests to improve the patient’s health outcomes and overall welfare. Nurses uphold this principle as they prioritize each patient’s individual needs while providing compassionate, patient-centered care that includes health promotion and disease prevention strategies. As a nurse, there will be instances, such as noncompliance that results in frequent hospitalizations, that make it difficult to provide compassionate patient-centered care. An example is patients with heart failure; heart failure has the highest 30-day readmission rate, which is mostly due to ineffective self-care (Alnomasy & Harmon Still, 2023). Despite the frustration in these types of situations, the nurse has an ethical duty to provide compassionate care.
Justice
The ethical principle of justice refers to treating all patients fairly and equitably. This principle requires that all individuals, regardless of race, age, sex, sexual orientation, gender identity, ethnicity, or social status, receive quality care with safe outcomes to ensure equitable distribution of health care and resources. Nurses should recognize and address social justice issues as well as advocate for policies and practices that promote health equity. Whereas equality means giving everyone access to the same resources regardless of their own special circumstances, equity takes into account individual challenges and advantages, and means providing assistance necessary to create an equal outcome for all, considering their circumstances (Figure 5.2). For example, when free flu vaccines are offered first to all older adults, we are using the ethical principle of justice. It is more equitable to administer the vaccines to older adults first because they are at higher risk.
Nonmaleficence
The ethical principle of nonmaleficence refers to the duty to do no harm, which we hear of as part of the Hippocratic Oath for medical doctors. It is also a foundational principle in nursing practice. This principle requires nurses to be vigilant, observant, and proactive while prioritizing potential risks and benefits of treatment options and simultaneously promoting healing, health, and well-being. All of these requirements can be achieved by selecting interventions that will cause the least amount of harm while also achieving the most beneficial outcome. For example, you may be caring for a mentally ill patient who has verbalized homicidal ideations that include a plan to harm someone and then themselves. As the patient’s nurse, you may feel torn regarding the patient’s privacy and the treatment plan that could divert the homicidal ideations (NCSL, 2022). However, a nurse’s duty is to do no harm while also ensuring the patient’s and other individuals’ safety (Loggins, 2023).
It is important to note that most states have laws in place that either require or permit health-care professionals to disclose information about patients who may become violent (NCSL, 2022). These laws have received increased attention following the increase of mass shootings. Some states, such as New York, have changed the reporting requirements from a permissive to a mandatory duty for health-care professionals to report when they believe a patient may pose a danger to themselves or others. A specific case in California, Tarasoff v. The Regents of the University of California (Laves, 1979), created a passage of “duty to warn” or “duty to protect” laws in almost every state. These laws afford health-care professionals immunity from civil and criminal liability for disclosure of confidential mental health information. The specific requirements vary by state, making it important to consult your risk management department when faced with a duty to warn or protect.
Fidelity
There is also the ethical principle of fidelity, which includes a model of care delivery that incorporates altruism, loyalty, caring, and honesty. For example, when an older adult patient with intact cognitive function is diagnosed with a terminal illness but they do not want to share this information with their family, it can create an ethical dilemma. This requires that no health-care information be shared without the patient’s consent to maintain the established trust between the patient and nurse. It also requires consultation within the interdisciplinary team members, such as case managers, social workers, and clergy, to identify community resources to provide support and services that the patient may need as their disease progresses.
Causes of Ethical Dilemmas
The human phenomenon of caring is the basis of the nursing profession. Though the nurse wants the best care for their patients, identification of the best care is not always easy; it may be compounded by an ethical dilemma. It is important for the nurse to be aware of major ethical dilemmas that are easily recognized, as well as daily interactions with patients and families that may give rise to ethical challenges that are not always easily recognized. Common topics that can create ethical dilemmas faced by nurses include
- Confidentiality of patient information, especially with the increased use and availability of computers
- End-of-life issues related to pain control, do not resuscitate (DNR) orders, do not intubate (DNI) orders, life support, or food and fluid issues
- Refusing to provide care for reasons ranging from a conflict in personal values to fear of personal risk of injury
- The use of restraints. It is important to weigh the risks of limiting a patient’s autonomy against the increased benefits to patient safety.
- Trust issues related to the use of placebos (an inactive substance used in place of the actual medication) when conducting nursing research or situations in which the family and provider have decided it is better to withhold certain information from a patient.
Ethical Decision-Making
It is inevitable that nurses will encounter ethical dilemmas in many challenging patient care situations. Determining the correct action for each situation can be very stressful. Through use of the ethical principles of autonomy, beneficence, nonmaleficence, and justice outlined by the ANA, a solid foundation is provided for ethical decision-making (ANA, 2015). This foundation is a guide to promote a logical, systematic framework for ethical decision-making.
The approach to ethical decision-making can follow the steps in the Clinical Judgement Measurement Model (Table 5.1).
| Step | Guidelines to Assist in the Ethical Decision-Making Process |
|---|---|
| Recognize and analyze cues (Assess the ethical/moral situation) |
|
| Prioritize hypotheses and generate solutions (Determine the nature of the dilemma, apply ethical principles, create potential courses of action) |
|
| Take actions (Consider potential consequences of options, list the alternatives) |
|
| Evaluate outcomes (Decide and evaluate the decision) |
|
Hospital ethics committees began to emerge in the early 1980s and, in time, became the primary source for dealing with ethical issues. Described in more detail later in the chapter, ethics committees provide support for health-care professionals when ethical challenges arise during clinical practice and are often consulted by nurses to help guide decision-making when ethical dilemmas are present during health-care delivery (Aulisio, 2016). Ethical dilemmas arise for a host of reasons (Hajibabaee et al., 2016) and can include the following:
- Assignments that are contradictory to personal cultural or religious beliefs or with the Code of Ethics for Nurses
- Complicated decision-making processes in health care
- Considerations associated with advancing medical technology
- Considerations to protect a patient’s rights
- Diversified beliefs related to medical involvement
- Diversity of lifestyles
- Diversity of morals, religious values, and cultural beliefs
- Incompetent peers
- Life and death decisions that must be made
- Patients refusing treatment
- Political and legal issues related to patient independence, euthanasia, and assisted dying
- Short-staffing or staff who fail to meet their responsibilities
Avoiding ethical dilemmas is impossible, but equipping yourself with knowledge to face these dilemmas is essential. The most important thing is to deal with each situation in a professional manner that promotes quality care and patient safety.
Link to Learning
This article from the Journal of Medical Ethics and history of Medicine provides an in-depth understanding of ethics committees and the ethical challenges faced by health-care providers.