Ethics is the part of philosophy that deals with the rightness or wrongness of human behav- ior. It is also concerned with the motives behind behaviors. Bioethics, specifically, is the application of ethics to issues that pertain to life and death. The implication is that judg- ments can be made about the rightness or goodness of healthcare practices.
Ethical codes are based on principles that can be used to judge behavior. Ethical princi- ples assist decision making because they are a standard for measuring actions. They may be the basis for laws, but they themselves are not laws. Laws are rules created by a governing body. Laws can operate because the govern- ment has the power to enforce them. They are usually quite specific, as are the punishments for disobeying them. Ethical principles are not confined to specific behaviors. They act as guides for appropriate behaviors. They also take into account the situation in which a deci- sion must be made. You might say that ethical principles speak to the essence or fundamen- tals of the law, rather than to the exactness of the law (Macklin, 1987). Here is an example:
Mrs. Van Gruen, 82 years old, was admitted to the hospital in acute respiratory distress. She was diagnosed with aspiration pneumonia and soon became septic, developing adult respiratory distress syndrome (ARDS). She had a living will, and her attorney was her designated healthcare surrogate. Her competence to make decisions was uncertain because of her illness. The physi-
cian presented the situation to the attorney, indicating that without a feeding tube and tra- cheostomy, Mrs. Van Gruen would die. Accord- ing to the laws governing living wills and healthcare surrogates, the attorney could have made the decision to withhold all treatments.
However, he felt he had an ethical obligation to still discuss the situation with his client. The client requested that the tracheostomy and the feeding tube be inserted, which was done.
In some situations, two or more principles may conflict with each other. Making a deci- sion under these circumstances is very diffi- cult. We now consider several of the ethical principles that are most important to nursing practice—autonomy, nonmaleficence, benefi- cence, justice, confidentiality, veracity, and accountability—and then look at some of the ethical dilemmas nurses encounter in clinical practice.
Autonomy
Autonomy is the freedom to make decisions for oneself. This ethical principle requires that nurses respect clients’ rights to make their own choices about treatment. Informed con- sent before treatment, surgery, or participa- tion in research is an example. To be able to make an autonomous choice, individuals need to be informed of the purpose, benefits, and risks of the procedures to which they are agreeing. Nurses accomplish this by providing information and supporting clients’ choices.
Nurses are often in a position to protect a client’s autonomy. They do this by ensuring that others do not interfere with the client’s right to proceed with a decision. If a nurse observes that a client has insufficient informa- tion to make an appropriate choice, is being forced into a decision, or is unable to under- stand the consequences of the choice, then the nurse may act as a client advocate to ensure the principle of autonomy.
Sometimes nurses have difficulty with the principle of autonomy because it also requires respecting another’s choice even if you dis- agree with it. According to the principle of autonomy, a nurse cannot replace a client’s decision with his or her own, even when the nurse honestly believes that the client has made the wrong choice. A nurse can, however, discuss concerns with clients and make sure they have thought about the consequences of the decision they are about to make.
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Nonmaleficence
The ethical principle of nonmaleficence requires that no harm be done, either deliber- ately or unintentionally. This rather compli- cated word comes from Latin roots:
non= not male= bad facere= to do
The principle of nonmaleficence also requires that nurses protect from danger individuals who are unable to protect themselves because of their physical or mental condition. An infant, a person under anesthesia, and a person with Alzheimer’s disease are examples of peo- ple with limited ability to protect themselves.
We are ethically obligated to protect our clients when they are unable to protect themselves.
This obligation to do no harm extends to the nurse who for some reason is not func- tioning at an optimal level. For example, a nurse who is impaired by alcohol or drugs is knowingly placing clients at risk. Other nurs- es who observe such behavior have an ethical obligation to protect the client according to the principle of nonmaleficence.
Beneficence
The word beneficence also comes from Latin roots:
bene= well facere= to do
The principle of beneficence demands that good be done for the benefit of others. For nurses, this is more than delivering competent physical or technical care. It requires helping clients meet all their needs, whether physical, social, or emotional. Beneficence is caring in the truest sense, and caring fuses thought, feeling, and action—knowing and being truly understanding of the situation and the thoughts and ideas of the individual (Benner
& Wrubel, 1989).
Sometimes physicians, nurses, and families withhold information from clients for the sake of beneficence. The problem with doing this is that it does not allow competent indi- viduals to make their own decisions based on all available information. In an attempt to be beneficent, the principle of autonomy is vio- lated. This is just one of many examples of the ethical dilemmas encountered in nursing prac- tice. For instance:
Mrs. Gonzalez has just been admitted to the oncology unit with ovarian cancer. She is sched- uled to begin chemotherapy treatment. Her two children and her husband have requested that the physician ensure that Mrs. Gonzalez not be told her diagnosis because they feel she would not be able to deal with it. The information is communicated to the nursing staff.
After the first treatment, Mrs. Gonzalez becomes very ill. She refuses the next treatment, stating that she didn’t feel sick until she came to the hospital. She asks the nurse what could pos- sibly be wrong with her that she needs a medi- cine that makes her sick when she doesn’t feel sick. Only people who get cancer medicine get this sick! Mrs. Gonzalez then asks the nurse,
“Do I have cancer?’’
As the nurse, you understand the order that the client is not to be told her diagnosis. You also understand your role as a patient advocate.
1. To whom do you owe your duty—the fam- ily or the client?
2. How do you think you may be able to be a client advocate in this situation?
3. What information would you communi- cate to the family, and how can you assist them in dealing with their mother’s con- cerns?
Justice
The principle of justice obliges nurses and other healthcare professionals to treat every person equally regardless of gender, sexual orientation, religion, ethnicity, disease, or social standing (Edge & Groves, 1994). This principle also applies in the work and educa- tional setting. Everyone should be treated and judged by the same criteria according to this principle. Here is an example:
Found on the street by the police, Mr. Johnson was admitted through the emergency room to a medical unit. He was in deplorable condition, wearing dirty, ragged clothes, unshaven, and covered with blood. His diagnosis was chronic alcoholism, complicated by esophageal varices and end-stage liver disease. Several nursing stu- dents overheard the staff discussing Mr.
Johnson. The essence of the conversation was that no one wanted to care for him because he was dirty, smelly, and brought this condition on himself. The students, upset by what they heard, went to their instructor about the situation. The instructor explained that every individual has a
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right to good care despite his or her economic or social position. This is the principle of justice.
Confidentiality
The principle of confidentiality states that anything said to nurses and other healthcare providers by their clients must be held in the strictest confidence. Exceptions exist only when clients give permission for the release of information or when the law requires the release of specific information. Sometimes, just sharing information without revealing an individual’s name can be a breach in confi- dentiality because the situation and the indi- vidual are identifiable. It is important to realize that what seems like a harmless state- ment can become harmful if other people can piece together bits of information and identi- fy the client.
Nurses come into contact with people from different walks of life. When working within communities, people are bound to know peo- ple, who know other people, and so on.
Individuals have lost families, jobs, and insur- ance coverage because nurses have shared confidential information and others have acted on that knowledge (AIDS Update Conference, 1995).
In today’s electronic environment the prin- ciple of confidentiality has become a major concern. Many healthcare institutions, insur- ance companies, and businesses use electronic media to transfer information. These institu- tions store sensitive and confidential informa- tion in computer databases. These databases need to have security safeguards to prevent unauthorized access. Healthcare institutions have addressed the situation through the use of limited access, authorization passwords, and security tracking systems. It is important to remember that even the most secure system developed is vulnerable and can be accessed by an individual who understands the com- plexities of computer systems.
Veracity
Veracity requires nurses to be truthful. Truth is fundamental to building a trusting relation- ship. Intentionally deceiving or misleading a client is a violation of this principle. Deliber- ately omitting a part of the truth is deception and violates the principle of veracity. This principle often creates ethical dilemmas. When is it all right to lie? Some ethicists believe it
is never appropriate to deceive another indi- vidual. Others think that if another ethical principle overrides veracity, then lying is per- missible. Consider this situation:
Ms. Allen has just been told that her father has Alzheimer’s disease. The nurse practitioner wants to come into the home to discuss treat- ment. Ms. Allen refuses, saying that the nurse practitioner should under no circumstances tell her father the diagnosis. She explains to the practitioner that she is sure he will kill himself if he learns that he has Alzheimer’s disease. She bases this concern on statements he has made regarding this disease.
The nurse practitioner replies that a medica- tion is available that might help her father.
However, it is available only through a research study being conducted at a nearby university. To participate in the research, the client must be informed of the purpose of the study, the med- ication to be given, its side effects, and follow- up procedures. Ms. Allen continues to refuse to allow her father to be told his diagnosis because she is positive he will commit suicide.
The nurse practitioner faces a dilemma:
does he abide by Ms. Allen’s wishes based on the principle of beneficence, or does he abide by the principle of veracity and inform his client of the diagnosis. What would you do?
Accountability
Accountability means accepting responsibility for one’s actions. Nurses are accountable to their clients and to their colleagues. When providing care to clients, nurses are responsi- ble for their own actions, good and not so good. If something was not done, do not chart or tell a colleague that it was. An example of violating accountability is the story of Anna:
Anna was a registered nurse who worked nights on an acute care unit. She was an excellent nurse, but as the acuity of the clients’ conditions increased, she was unable to keep up with both clients’ needs and the technology, particularly IVs. She began to chart that all the IVs were infusing as they should, even when they were not. Each morning, the day shift would find that the actual infused amount did not agree with what the paperwork showed. One night, Anna allowed an entire liter to be infused into a client with congestive heart failure in 2 hours. When the day staff came on duty, they found the client expired, the bag empty, and the tubing filled with blood. Anna’s IV sheet showed 800
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mL left in the bag. It was not until a lawsuit was filed that Anna took responsibility for her behavior.
The idea of a standard of care evolves from this principle. Standards of care provide a ruler for measuring nursing actions.