TYPES OF ETHICAL PROBLEMS IN NURSING
As a profession, nursing is accountable to society. This account-ability is spelled out in the American Hospital Association’s Patient Care Partnership (Chart 3-3), 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 (Chart 3-4), established by the American Nurses Association (ANA), consists of ethical standards, each with its own interpre-tive statements (ANA, 2001). The interpretive statements provide guidance to address and resolve ethical dilemmas by incorporating universal moral principles (ANA’s Code of Ethics Project Task Force, 2000). 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 Pol-icy Statement (1995), defines nursing as “the diagnosis and treat-ment 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 logi-cal, 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 set-tings, 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 numer-ous 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.
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 pa-tient with other members of the health care team is often neces-sary. 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 (Zolot, 1999). For example, laboratory results regarding testing for human immuno-deficiency 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 (see Chart 3-2) to the patient, sensitivity to the principle of confidentiality is essential.
The use of restraints (including physical and pharmacologic mea-sures) is another issue with ethical overtones. It is important to weigh carefully the risks of limiting a person’s autonomy and in-creasing 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 (Rogers & Bocchino, 1999). The Joint Commission on Accredi-tation of Healthcare Organizations (JCAHO) and the Health Care Financing Administration (HCFA) have designated standards for use in care of patients with restraints; these standards are available on the website listed later.
Telling the truth (veracity) is one of the basic principles of our culture. Two ethical dilemmas in clinical practice that can di-rectly conflict with this principle are the use of placebos (non-active substances used to treat symptoms) and not revealing a di-agnosis 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 un-dermine the nurse–patient relationship.
Informing patients of their diagnoses when the family and physician have chosen to withhold information is a common eth-ical situation in nursing practice. The nursing staff often use evasive comments with the patient as a means to maintain profes-sional relationships with other health practitioners.
This area is in-deed complex because it challenges the nurse’s integrity. Trust and connection with the patient play an important part in optimizing care (Day & Stannard, 1999). Strategies the nurse could consider in this situation include the following:
• Not lying to the patient
• Providing all information related to nursing procedures and diagnoses
• 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, fami-lies may change their perspective. Finally, although providing the information may be the morally appropriate behavior, the man-ner 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.
Any nurse who feels compelled to refuse to provide care for a par-ticular type of patient faces an ethical dilemma. The reasons given for refusal range from a conflict of personal values to fear of per-sonal risk of injury. Such instances have increased since the ad-vent 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 re-garding the patient population. If one is uncomfortable with a par-ticular 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.
Dilemmas that center on death and dying are prevalent in medical-surgical nursing practice and frequently initiate moral discussion. The dilemmas are compounded by the fact that the idea of curing is paramount in health care. With advanced technology, it may be difficult to accept the fact that nothing more can be done, or that technology may prolong life but at the expense of comfort and quality of life. Focusing on the caring as well as the curing role may assist nurses in dealing with these difficult moral situations.
The use of opioids to alleviate a patient’s pain may present a dilemma for nurses. Patients with excruciating pain may require large doses of analgesics. Fear of respiratory depression or un-warranted fear of addiction should not prevent nurses from at-tempting to alleviate pain for the dying patient or for a patient experiencing an acute pain episode. In the case of the terminally ill patient, for example, the actions may be justified by the princi-ple of double effect (see Chart 3-2). The intent or goal of nursing interventions is to alleviate pain and suffering while promoting comfort. The risk of respiratory depression is not the intent of the actions and should not be used as an excuse for withholding anal-gesia. However, the patient’s respiratory status should be carefully monitored and any signs of respiratory depression reported to the physician. The administration of analgesia should be governed by the patient’s needs.
The “do not resuscitate” (DNR) order is a controversial issue. When a patient is competent to make decisions, his or her choice for a DNR order should be honored, according to the principles of autonomy or respect for the individual (Trammelleo, 2000). However, a DNR order is at times interpreted to mean that the patient requires less nursing care, when actually these patients may have significant medical and nursing needs, all of which de-mand attention. Ethically, all patients deserve and should receive appropriate nursing interventions, regardless of their resuscita-tion status.
In contrast to the previous situations are those in which a DNR decision has not been made by or for a dying patient. The nurse may be put in the uncomfortable position of initiating life-support measures when, because of the patient’s physical condition, they appear futile. This frequently occurs when the patient is not competent to make the decision and the family (or surrogate de-cision maker) refuses to consider a DNR order as an option. The nurse may be told to perform a “slow code” (ie, not to rush to re-suscitate the patient) or may be given a verbal order not to resus-citate the patient; both are unacceptable medical orders. The best recourse for nurses in these situations is to be aware of hospital policy related to the Patient Self-Determination Act (discussed later) and execution of advance directives. The nurse should communicate with the physician. Discussing the matter with the physician may lead to further communication with the family and to a reconsideration of their decision, especially if they are afraid to let a loved one die with no further efforts to resuscitate (Trammelleo, 2000). Finally, when working with colleagues who are confronting such difficult situations, it helps to talk and lis-ten to their concerns as a way of providing support.
In addition to requesting that no heroic measures be taken to pro-long life, a dying patient may request that no more food or fluid be administered. Many individuals think that food and hydration are basic human needs, not “invasive measures,” and therefore should always be maintained. However, some consider food and hydration as means of prolonging suffering. In evaluating this issue, nurses must take into consideration the potential harm as well as the benefit to the patient of either administering or with-drawing sustenance. Research has not supported the belief that withholding fluids results in a painful death due to thirst (Smith, 1997; Zerwekh, 1997).
Evaluation of harm requires a careful review of the reasons the person has requested the withdrawal of food and hydration. Although the principle of autonomy has considerable merit and is supported by the Code of Ethics for Nurses, there may be sit-uations when the request for withdrawal of food and hydration cannot be upheld. For patients with decreased decision-making capacity, the issues are more complex. Some of these cases have reached courts of law, and different states have different case law precedents forbidding withdrawal of sustenance. Although an ad-vance directive may provide some answers, at present there are no firm guidelines to assist nurses in this area.