Ethical Aspects of Nursing
Ethical Aspects of Nursing
The science of ethics studies the relationships between moral actions and values and how these affect society. The word ethics refers to values that influence a person’s behavior and the individual’s feelings and beliefs about what is right or wrong. Nursing ethics involve moral values and principles that affect personal and professional conduct. As previously mentioned, the LPN/LVN has the responsibility to practice within the legal and ethical boundaries of nursing practice. Nursing ethics propose the duties and obligations of nurses to their patients, other health care professionals, the profession itself, and society.
Advance Directives
Advance directives are signed and witnessed documents that provide specific instructions for health care treatment in the event that a person is unable to make these decisions personally at the time they are needed.
The two basic types of advance directives are living wills and durable powers of attorney for health care. Many patients have instituted one or both.
The Patient Self-Determination Act (PSDA; 1991) requires health care institutions to provide written information to patients concerning the patient’s rights under state law to make decisions, including the right to refuse treatment and formulate advance directives. It is especially important to understand patients’ cultural beliefs and values when explaining advance directives. Regulatory mandates to benefit the public are based on the dominant value in American society of self-determination, which may be in conflict with a patient’s cultural heritage.
Under the act, whether the patient has signed an advance directive must be documented in the patient’s record. The hospital is also required to ensure that state law is followed. The institution must provide education for the staff and the public concerning living wills and durable powers of attorney. For either type of advance directive to be enforceable, the patient must be legally incompetent or lack capacity to make decisions regarding health care treatment. The termination of legal competency is made by a judge, and the determination of decisional capacity is usually made by the physician and the family. Therefore, the advance directive is implemented within the context of the health care team and the health care institution. One should be familiar with the institution’s policies involving the act.
A living will is a written document that directs treatment in accordance with a patient’s wishes in the event of a terminal illness or condition (Figure 2-5). Living wills are often difficult to interpret and are not clinically specific in unforeseen circumstances. Each state has its own requirements for executing living wills. Generally, the presence of two witnesses is required when the patient signs the document; neither may be a relative or physician. If health care workers follow the directions of the living will, they are immune from liability.
A durable power of attorney for health care designates an agent, surrogate, or proxy to make health care decisions on the patient’s behalf based on the patient’s wishes.
In addition to federal statutes, the ethical doctrine of autonomy ensures the patient the right to refuse medical treatment. This right was upheld in the Bouvia v Superior Court case in 1986. That case allowed the discontinuation of the patient’s tube feedings as per the patient’s prior request. The courts have also upheld the right of a legally competent patient to refuse medical treatment based on religious beliefs. Jehovah’s Witnesses, for example, accept medical treatment but refuse blood transfusions. In the absence of a truly compelling reason otherwise, the right to make such choices is protected. The U.S. Supreme Court stated in the Cruzan v Director, Missouri Department of Health case in 1990 that “we assume that the U.S. Constitution would grant a constitutionally protected competent person the right to refuse lifesaving hydration and nutrition.” In cases that involve the patient’s right to refuse or withdraw medical treatment, the courts balance the patient’s interest with the state’s interest in protecting life, preserving medical ethics, preventing suicide, and protecting innocent third parties. Children are generally considered innocent third parties. Although the courts do not force adults to undergo treatment that is refused for religious reasons, they do grant an order that allows hospitals and physicians to treat children of Christian Scientists or Jehovah’s Witnesses who have denied consent for treatment of their minor children.
When patients are legally incompetent and are unable to make health care decisions, the court steps in. Balancing the state’s interest with that of the patient, the court attempts to deliver a judgment that represents what the patient would have chosen if competent. The Supreme Court held in the Cruzan case that states had the right to require “clear and convincing evidence” of a legally incompetent patient’s prior wishes when making determinations to discontinue life-sustaining treatment. In that case, nutrition and hydration were recognized as life-sustaining medical treatment that could be withdrawn.
Every state now requires “clear and convincing” evidence of the patient’s choice, but individual states differ as to what standard satisfies the requirement. In the absence of evidence indicating the patient’s prior choice, most states allow treatment to be stopped based on other factors, including the best interest of the patient balanced with the state’s interest (Box 2-7).
Development of Ethical Principles
Values are personal beliefs about the worth of an object, an idea, a custom, or an attitude. Values vary among people and cultures; they develop over time and undergo change in response to changing circumstances and necessity. Each individual adopts a value system that governs what is deemed as right or wrong (or good and bad) and influences behaviors in a given situation.
Values influence everyday decisions. Each person has many values and at times has to choose between competing or conflicting values. Some values are more important than others, and the choices made are based on the priority placed on each particular value. A person’s values are learned through experience, observation, and reasoning. Some values are consciously chosen; others are adopted unconsciously. As children, society has a strong influence on behaviors and values retained and learned. Acceptable behavior is rewarded, and unacceptable behavior is punished. The development of an individual value system occurs with maturity and largely reflects culture (see Cultural Considerations box).
Nurses must reflect on and assess the values held. Value clarification is the process of self-evaluation that helps gain insight into personal values. To clarify
values, do the following: (1) select the belief or behavior and consciously examine it; (2) decide its value; and (3) incorporate the value into everyday responses and behaviors. These steps exercise freedom of choice and determine which values are of most importance. Nurses are in a unique position of having the ability to assist in value clarification as well, by encouraging the patient to express feelings and thoughts related to a situation, without contributing personal opinions. Patients need to act on their own values, not those of the nurse. Sometimes the patient may be referred to a clergy member or other professional who can help deal with ethical issues. Most health care institutions have an ethics committee to help resolve ethical questions that arise and to act as an advising body for issues encountered.
Ethical dilemmas are situations that do not have a clear right or wrong answer (Box 2-8). They are complex, confusing, and often frustrating situations that call for careful rational analysis. First, the problem needs to be identified as an ethical one. This means that the question presented cannot be answered by applying external laws, rules, policies, and procedures. Many situations present a combination of legal and ethical questions. It is important to sort out the questions and seek guidance as needed. The next step is complete assessment of the situation, with as much information as possible gathered to aid in the decision-making process. Before a decision is finalized, any ethical principles that might apply to the situation should be considered. Ethical principles are general in nature, but they provide a framework for decision making.
Ethical Principles in Nursing Practice
In health care, several common ethical principles are important for consideration when confronted with an ethical question. The first, most fundamental principle is respect for people. This principle leads us to view all human life as sacred, with each individual having inherent worth as a person. To the nurse, this principle means that no one person is more important than another; each patient has the same worth and is always entitled to respect. Autonomy is another ethical principle; it refers to freedom of personal choice, a right to be independent and make decisions freely. Frequently the patient may ask the nurse for opinions or assistance in making decisions. The nurse does not have the authority to make decisions for the patient. Beneficence means doing good or acting for someone’s good; this principle is one of primary importance to nurses. The nurse has an ethical duty to protect life and promote the well-being of all patients. Another ethical principle is nonmaleficence, which means to do no harm. It is paramount to nursing practice to act in the patient’s best interest and an ethical and legal duty to do nothing that has a harmful effect on the patient. Finally, there is the principle of justice, or the concept of what is fair. In the context of nursing, justice means that all patients have the same right to nursing interventions.
It is a great challenge to the nurse to balance these ethical principles when they seem in conflict. Rarely are options clear or black and white. Decisions often come down to choosing what seems more right and less wrong, more good and less bad.
Codes of Ethics
As a member of society and the health care community, nurses use both personal and professional ethical principles to govern professional practice. Professional organizations have developed codes of ethics for the nursing profession that serve as a way to regulate the nurses’ actions and give guidelines for ethical behavior. By helping health care practitioners become more competent, trustworthy, and accountable, such codes of ethics help safeguard society. The National Federation of Licensed Practical/Vocational Nurses (NFLPN) has developed a code for LPN/LVNs. This code specifies what is expected: (1) to know and function within the scope of practice for a licensed LPN/LVN; (2) to maintain patient confidences; (3) to provide health care without discrimination; (4) to maintain a high degree of professional and personal behavior; and (5) to take an active role in the development of the LPN/LVN profession. The ANA and the CNA have also developed codes of ethics that specify the ethical duties required of the nursing professional.
Reporting Unethical Behavior
Nurses have a duty to report behavior witnessed that does not meet the established standards. Unethical behavior involves failing to perform the duties of a competent caring nurse. When reporting unethical behavior, one should always follow the proper chain of command and explain the facts as clearly as possible. Any documentation of the incident must be objective and accurately state what occurred, when and where it occurred, and any other pertinent facts. Reporting a coworker is never an easy task. Always remember, however, that a nurse’s first duty is to the patient’s health, safety, and well-being.
Ethical Issues
Ethical issues are difficult for the nurse, as for everyone, because there is no absolutely right or absolutely wrong answer to the question the issue presents. Like many other issues in health care, ethical issues change as society changes. Some of the current ethical issues in nursing include practitioner-assisted suicide (PAS), the right to refuse treatment, the nurse’s right to refuse to provide care, and genetic research.
Practitioner-Assisted Suicide
Health care professionals and patient advocacy groups on both sides of the issue are debating the ethics of PAS. Also called physician-assisted suicide, this is a form of active euthanasia in which a health care provider takes an active role in ending a patient’s life. Two cases, Vacco v Quill and Washington v Glucksberg, were brought before the U.S. Supreme Court regarding the legality of state bans on assisted suicide. The Supreme Court ruled in 1997 that there is no constitutional right to assisted suicide. This ruling allows each state to decide whether to legalize or ban assisted suicides. The ANA has taken a firm stand on the issue of PAS, holding that PAS is not consistent with the philosophy of nursing. ANA’s specific objections to PAS are based on the principle of nonmaleficence, to do no harm, and beneficence, the duty to protect life.
In 1944, the ANA adopted a position statement concerning PAS. The ANA wrote that such an act is in violation of the Code of Ethics for Nurses and the ethical tradition of the profession. Nurses have an obligation to provide compassionate end-of-life care that includes providing comfort and pain relief. Proponents of PAS, however, cite the ethical principles of the right to autonomy and the right to self-determination in support of their position.
Right to Refuse Treatment
In the context of health care, competent adults have the right to refuse treatment. This right derives from their right to determine what is done, or not done, to them. Medicine’s technical capacity to sustain life and postpone death further complicates this complex issue. It is the right of the patient to accept or refuse a treatment, even if the refusal has the potential to or is certain to result in death. To exercise the right to refuse treatment, many patients prepare advance directives. Living wills, one kind of advance directive, become effective when patients are incapacitated and are not able to make their own wishes known; these documents specify which lifesaving treatments are acceptable and which are not. Some patients choose to designate a health care proxy (assign durable power of attorney) to make decisions regarding medical treatment in the event that the patient becomes unable to make them. The proxy is another person who will speak for the patient and make decisions regarding the patient’s care. The proxy is obligated to act on the patient’s behalf according to the patient’s expressed wishes. State laws vary on the legalities of the various forms of advance directives, and nurses need to know the applicable laws in their state.
Do-Not-Resuscitate Orders
The patient is not usually involved directly at the time a do-not-resuscitate (DNR) order is written. Although many people make their wishes regarding DNR status known in an advance directive, at this stage the patient is usually incapacitated with little hope for recovery. The physician, after consultation with the patient’s family, writes the DNR order in the medical record. The physician is responsible for following the applicable policies and procedures for writing DNR orders. When a DNR order is written in the chart, the nurse has the duty to follow the order.
Refusal to Treat
Refusal to treat is an issue that arises when a patient’s care requires a nurse to do something that conflicts with his or her personal moral beliefs. A typical example of this dilemma involves assisting in or caring for a woman having an abortion. There is a legal right to abortion, but this does not establish whether abortion is morally right or wrong. If the nurse has a strong moral or religious belief regarding abortion, these concerns must be communicated with the appropriate supervisor. Do not abandon the patient; instead, ask for another assignment. Remember that the right to disqualify oneself from assisting with an abortion does not extend to the complete ability to avoid caring for the patient after the abortion. Disagreement with care decisions made by patients does not allow the nurse to refuse to care for them.
Patient diagnoses and lifestyles do not allow the nurse the legal right to refuse to care for a person. Examples include an infectious disease, such as HIV, or sexual orientation. The rationale is that the need for standard precautions (infection control measures) applies to every patient, and therefore, the nurse is at no greater risk for infection from one patient than from another. The ethical principle of respect for all people without discrimination underlies this issue. The patient has the right to receive care, and the nurse has the responsibility to provide nursing interventions.