As a profession, nursing is accountable to society. This accountability is spelled out in the American Hospital Association’s Patient Care Partnership, which reflects social beliefs about health and health care. In addition to accepting this document as one measure of accountability, nursing has further defined its standards of accountability through a formal code of ethics that explicitly states the profession’s values and goals. The code established by the American Nurses Association (ANA), consists of ethical standards, each with its own interpretive statements. The interpretive statements provide guidance to address and resolve ethical dilemmas by in corporating universal moral principles. The code is an ideal framework for nurses to use in ethical decision making.
Ethical issues have always affected the role of the professional nurse. The accepted definition of professional nursing has inspired a new advocacy role for nurses. The ANA, in Nursing’s Social PolicyStatement (1995), defines nursing as “the diagnosis and treatment of human responses to health and illness.” This definition supports the claim that nurses must be actively involved in the decision-making process regarding ethical concerns surrounding health care and human responses. Efforts to enact this standard may cause conflict in health care settings in which the traditional roles of the nurse are delineated within a bureaucratic structure. If, however, nurses learn to present ethical conflicts within a logical, systematic framework, struggles over jurisdictional boundaries may decrease. Health care settings in which nurses are valued members of the team promote interdisciplinary communication and may enhance patient care. To practice effectively in these settings, nurses must be aware of ethical issues and assist patients in voicing their moral concerns. The basic ethical framework of the nursing profession is the phenomenon of human caring. Nursing theories that incorporate the biopsychosocial–spiritual dimensions emphasize a holistic viewpoint, with humanism or caring as the core. As the nursing profession strives to delineate its own theory of ethics, caring is often cited as the moral foundation. For nurses to embrace this professional ethos, it is necessary to be aware not only of major ethical dilemmas but also of those daily interactions with health care consumers that frequently give rise to ethical challenges that are not as easily identified. Although technological advances and diminished resources have been instrumental in raising numerous ethical questions and controversies, including life-and-death issues, nurses should not ignore the many routine situations that involve ethical considerations. Some of the most common issues faced by nurses today include confidentiality, use of restraints, trust, refusing care, genetics, and end-of-life concerns.
Confidentiality
We all need to be aware of the confidential nature of information obtained in daily practice. If information is not pertinent to a case, the nurse should question whether it is prudent to record it in the patient’s chart. In the practice setting, discussion of the patient with other members of the health care team is often necessary. These discussions should, however, occur in a private area where it is unlikely that the conversation will be overheard. Another threat to keeping information confidential is the widespread use of computers and the easy access people have to them. This may increase the potential for misuse of information, which may have negative social consequences. For example, laboratory results regarding testing for human immunodeficiency virus (HIV) infection or genetic screening may lead to loss of employment or insurance if the information is disclosed. Because of these possibilities of maleficence to the
patient, sensitivity to the principle of confidentiality is essential.
Restraints
The use of restraints (including physical and pharmacologic measures) is another issue with ethical overtones. It is important to weigh carefully the risks of limiting a person’s autonomy and increasing the risk of injury by using restraints against the risks of not using restraints. Before restraints are used, other strategies, such as asking family members to sit with the patient, should be tried. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Health Care Financing Administration (HCFA) have designated standards for use in care of patients with restraints.
Trust Issues
Telling the truth (veracity) is one of the basic principles of our culture. Two ethical dilemmas in clinical practice that can directly conflict with this principle are the use of placebos (nonactive substances used to treat symptoms) and not revealing a diagnosis to the patient. Both involve the issue of trust, which is an essential element in the nurse–patient relationship. Placebos may be used in experimental research, where the patient is involved in the decision-making process and is aware that placebos are being used in the treatment regimen. However, the use of a placebo as a substitute for an active drug to show that the patient does not have real symptoms is deceptive. This practice may severely undermine the nurse–patient relationship. Informing patients of their diagnoses when the family and physician have chosen to withhold information is a common ethical situation in nursing practice. The nursing staff often use evasive comments with the patient as a means to maintain professional relationships with other health practitioners. This area is indeed complex because it challenges the nurse’s integrity. Trust and connection with the patient play an important part in optimizing care. Strategies the nurse could consider in this situation include the following: 1) Not lying to the patient 2)Providing all information related to nursing procedures and diagnoses 3) Communicating to the family and physician the patient’s
requests for information
Families often are unaware of the patient’s repeated questions to the nurse. With a better understanding of the situation, families may change their perspective. Finally, although providing the information may be the morally appropriate behavior, the manner in which the patient is told is important. Nurses must be compassionate and caring while informing patients; disclosure of information merely for the sake of patient autonomy does not convey respect for others.
Refusing to Provide Care
Any nurse who feels compelled to refuse to provide care for a particular type of patient faces an ethical dilemma. The reasons given for refusal range from a conflict of personal values to fear of personal risk of injury. Such instances have increased since the advent of acquired immunodeficiency syndrome (AIDS) as a major health problem. In one survey, the number of nurses who stated they might refuse to care for a patient with AIDS declined over a 10-year period, from 75% to 20%. The number who might refuse to care for a patient with AIDS who was violent or uncooperative, however, rose from 72% to 82% (Ventura, 1999). The ethical obligation to care for all patients is clearly identified in the first statement of the Code of Ethics for Nurses. To avoid facing these moral situations, a nurse can follow certain strategies. For example, when applying for a job, one should ask questions regarding the patient population. If one is uncomfortable with a particular situation, then not accepting the position would be an option. Denial of care, or providing substandard nursing care to some members of our society, is not acceptable nursing practice.