Nursing is a moral profession. Nurses are charged to do good for their patients and avoid harm. Although the new discipline of bioethics defines the principles of respect for autonomy, nonmaleficence, beneficence and justice, these concepts have always been a part of nursing. But technological advances in healthcare require that nurses expand their instinctive understanding of ethics into one of reasoned and deliberate knowledge. There are several ways nurses can turn their understanding into knowledge.
When nurses read and reflect on the American Nurses Association 2001 Code of Ethics for Nurses with Interpretive Statements,1
they gain a deeper understanding of the ethical principles that guide the profession. When they join a nursing ethics committee, nurses can clarify their thinking about the ethical dilemmas they encounter in the workplace. Nurses who have a special interest in ethics may want to earn an advanced degree in bioethics. And finally, when nurses gain insight into the ethical issues of managed care, they can advocate for the healthcare of the broader community.
Code of Ethics for Nurses
A code of ethics is a guide for an individual or group to follow in making decisions regarding ethical issues. Ethics are the principles that guide an individual, group or profession in conduct.2
The first code of ethics for nurses, referred to as the Nightingale Pledge
, was patterned after the physicians’Hippocratic Oath
and adopted in 1893. Other codes were suggested in 1926 and 1940, but it wasn’t until 1950 that the ANA House of Delegates adopted the Code for Professional Nurses, with 17 provisions. In 1985, another code condensed the original 17 provisions to 11 and added interpretive statements. The latest Code of Ethics for Nurses with Interpretive Statements, adopted in 2001, is the first revision in 25 years.1
All the nursing codes address the importance of the principles of doing no harm, benefiting others, loyalty, truthfulness and social justice. Later versions include the importance of patient and nurse autonomy.1 The 2001 code recognizes that the present-day context of nursing practice has changed and expanded, and it places a new emphasis on nursing advocacy. It stresses the need for healthcare as one of the most important moral challenges of the 21st century and calls on nurses to have a true global awareness about the human condition.1
The 2001 Code of Ethics for Nurses with Interpretive Statements has nine provisions. Together they describe the fundamental values and commitments of the nurse, the boundaries of duty and loyalty, and nurses’ duties beyond patient encounters.1
1. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every patient, unrestricted by social or economic status, personal attributes or the nature of health problems.1
This provision of the code means that the nurse respects the human dignity of every patient, treats patients without prejudice regardless of the nature of their health problems and supports their rights to self-determination while maintaining compassionate relationships with colleagues.1
Nurses can show respect for a patient’s dignity in ways as simple as to close the privacy curtain when giving care or to address the patient in a respectful manner.
To practice with respect also means to provide care without prejudice toward a person’s cultural values, lifestyle, religious beliefs, disease or disability. It means that in all professional relationships, the nurse transcends his or her personal fundamental assumptions about people and treats all patients with compassion and respect, even those some people might deem “difficult.”
It also means providing care without prejudice toward a person who is close to death. For patient care at the end of life, the code stresses that nurses should minimize suffering and relieve the pain of a dying patient even if those interventions hasten death, as long as the nurse’s sole intent is not to end the patient's life.1
Respect for human dignity also means respect for the right to self-determination. In this provision, the code expresses the basic bioethical principle of autonomy that forms the basis of informed consent in healthcare. Respect for the patient’s autonomy and self-determination means that the nurse has the ethical obligation to support a patient’s decision. Even when a nurse and a physician believe that a proposed procedure is in the best interests of a patient, the patient has the right to refuse the procedure at any time, regardless of whether he or she signed a consent form.5
The nurse’s role in informed consent is to ensure that the patient has all the necessary information to make an autonomous decision. For example, a perioperative nurse, with a patient who is anxious because he or she does not understand fully what will occur during surgery, would follow the ethical principle of respect when he or she places the emotional needs of the patient above the expectation of the OR to expedite the surgical schedule.3 The criterion is whether the patient is an adult who is capable of making a decision and who has all the information necessary to make an autonomous choice.5
Nurses who work in institutions that do not allow them to answer patients’ questions about treatment options may come into conflict with the code’s obligation to advocate for the patient’s right to self-determination. Nurses need to be aware of the legal rights of patients and the resources within the community that uphold those rights. State health agencies can investigate complaints by or for hospital patients and long-term care residents; and an ombudsperson in the Ombudsman Program
,provided for by the Older Americans Act, can investigate and resolve complaints made by or for residents in long-term care facilities. Complaints, including anonymous complaints, can be made to the appropriate agency when patients’ rights are not respected.
The code’s principle of respect for others also extends to nurses’ relationships with assistants, colleagues, employees and students. It emphasizes the importance to maintain a compassionate commitment to fair treatment and stresses a commitment to integrity-preserving compromises to resolve conflict.1
2. The nurse’s primary commitment is to the patient, whether a person, family, group or community.1
When caring for a community and resources are limited or managed, the principle of distributive justice—the sharing of burdens and benefits in the allocation of resources—is important. This includes the allocation of the nurse’s skill, attention and time.3Whether the patient is a person, family, group or the community, the nurse is expected to place the interests of the patient first even in the face of conflicting workplace loyalties, and the nurse is expected to collaborate with colleagues, within professional boundaries, to meet the patient’s needs.
When the wishes of the patient are in conflict with families, physicians or the healthcare organization, nurses should try to resolve the conflict in ways that ensure the safety and best interests of the patient, as well as preserving their professional integrity. If the nurse cannot resolve the conflict, he or she remains committed to the patient.1
In today’s healthcare system, nurses may be pressured to reduce spending or provide care to patients based on bonuses and incentives. Nurses who must choose between their economic self-interest and their primary commitment to the patient find themselves in a conflict of interest as well as an ethical conflict.1
Just how widespread this conflict of interest is was shown by an ANA survey of 1,137 nurses. Seventy-six percent of the nurses reported that their ability to exercise patient advocacy was increasingly constrained in the present healthcare environment. Sixty-four percent said financial incentives created conflicts of interest that affected patient care, and 49% said their most frequent concern was cost-containment that jeopardizes patient welfare.6
When nurses find themselves in perceived or actual conflicts of interest, the code encourages them to disclose fully their conflict in the matter to all relevant parties, including colleagues, employees and patients and, in some situations, withdraw from future participation.1 Equal treatment of patients is mandated not only by the ethical principles of beneficence, justice and nonmaleficence, but also by regulatory and accrediting agencies.6
Another way nurses maintain their primary commitment to the patient is to work with other members of the healthcare team to articulate clearly the healthcare needs of the patient and to make sure that all relevant parties have a voice in decision making.1
The nurse’s primary commitment to the patient can also be in jeopardy when a too-close relationship with a patient or a colleague exists. When intimacy with a patient or a close relationship with a colleague threatens to undermine the professional relationship with the patient, the code counsels nurses to seek assistance from peers or supervisors or to withdraw from the situation.1
3. The nurse promotes, advocates for and strives to protect the health, safety and rights of the patient.1
The theoretical root of Provision No. 3 is the respect for autonomy, which nurses are expected to preseve and safeguard.3 Nurses do this when they promote the privacy and confidentiality of patients and protect the safety of all patients, including those who are the subjects of research. Nurses are also expected to promote professional standards and act on the questionable or impaired practice of anyone whose practice threatens the health, rights or safety of the patient.
Nurses need to advocate for the rights of patients to physical privacy, privacy for their discussions and privacy of their confidential information, whether electronic, oral or written. This bioethical expression of the rule of confidentiality derives from the principle of respect for patient autonomy. Nurses should share patient information only with members of the healthcare team who need to know. Third-party payers should have access only to patient information under defined protocols within written guidelines, and special efforts should be taken to maintain the security of electronic communications.1
Privacy and confidentiality associated with genetic testing are especially important as access to personal health information becomes more widespread.6 The availability of such data places patients with untreatable or resource-intensive conditions at risk for discriminatory practices such as denial of healthcare coverage or employment.6
Nurses must protect the rights of research patients and be especially vigilant in protecting vulnerable groups, such as children, prisoners, students, the elderly and the poor. Patients who contemplate involvement in a research project must be given enough information to enable them to make an informed choice.1 Such information should include the nature of their participation, the risks vs. benefits and the fact that they have the right to choose whether to participate or refuse to be involved. Patients also need to know that they can withdraw at any time without adverse consequences or reprisals and how to discontinue their participation.6The code states that nurses have the duty to question, to report if necessary and to refuse to participate in research that they consider morally objectionable.1
Nurses protect the health, rights and safety of patients when they allow only those people with integrity, knowledge and skill to enter and practice in the profession. Nursing educators must educate and nursing administrators must be aware of nurses’ knowledge and skills before they assign them responsibilities.1
Nurses also protect the safety of patients when they are alert to the illegal, incompetent, impaired or unethical practice of anyone who puts the rights of patients in jeopardy. If this occurs, the nurse should notify the appropriate supervisor.1 If a healthcare organization threatens the welfare of patients, the code advises nurses to contact the organization’s administrator and appropriate higher authority if necessary.1