A code of ethics is a guide for an individual or group to follow in making decisions regarding ethical issues.
In the broadest sense, ethics are the principles that guide an individual, group, or profession in conduct. Although nurses do make independent decisions regarding patient care, they are still responsible to the profession as a whole in how those decisions are made. From the earliest concept of nursing, the proper behavior and conduct of a nurse was closely scrutinized. Florence Nightingale wrote of specific issues of conduct and moral behavior. The Nightingale pledge that was composed in 1893 by nursing instructor Lystra Gretter includes the vow "to abstain from whatever is deleterious and mischievous and will not take or knowingly administer any harmful drug."
Over the last 100 years, nursing has evolved into a very complex professional field. Nurses are now faced with life and death decisions, sometimes on an hourly basis. Medical care has advanced to the point that new technology with its potential benefit or harm to a patient changes constantly. Although the private conduct of a nurse is no longer controlled by the employer, the effects of that lifestyle on the nurse's ability to think and respond to patients while on duty falls under the code of ethics.
The study of ethics is actually a branch of philosphy. The word ethics is derived from the Greek term ethos which means customs, habitual usage, conduct, and character. The study of ethics has led to the identification of basic concepts including rights, autonomy, beneficence, nonmaleficence, justice, and fidelity. Understanding these concepts assists the nurse with making decisions during difficult situations.
Webster defines a right as "something to which one has a just claim or the power or priviledge to which one is justly entitled." Patient rights have evolved to the point that federal legislation has been passed in the United States to protect a patient's individual rights. A Patient's Bill of Rights was initially developed by the American Hospital Association in 1973 and revised in1992. All hospitals are now required by law to inform patients of these rights upon admission to the hospital.
Autonomy comes from the latin auto meaning "self" and nomy which means "control." Individuals must be given the rights to assist in their own decision making. This ethical concept has led to the need for informed consent. Sometimes patients' religious or cultural beliefs lead them to make decisions regarding their own care that may seem controversial or even dangerous. However, the concept of autonomy gives them the right to make those decisions unless they are mentally impaired.
Beneficence and nonmaleficence
Beneficence means to do good, not harm, to other people. Nonmaleficence is the concept of preventing intentional harm. Both of these ethical concepts relate directly to patient care. In the American Nurses Association Code for Nurses, there is a specific charge to protect patients by specifying that nurses should report unsafe, illegal, or unethical practices by any person. Nurses are often faced with making decisions about extending life with technology, which might not be in the best interest of the patient. Often the concept of weighing potential benefit to the patient against potential harm is used in making these difficult decisions, along with the patient's own stated wishes.
The word justice is closely tied with the legal system. However, the word refers to the obligation to be fair to all people. In 2001, healthcare economics have hospitals and other providers stretching their resources to their limits. Economic decisions about healthcare resources have to be made based on the number of patients who would benefit. The potential of rationing care to the frail elderly, poor, and disabled creates an ethical dilemma that is sure to become even more complicated in the future.
Fidelity refers to the concept of keeping a commitment. Although the word is more closely used to describe a marital relationship, fidelity is the concept of accountability. What is the nurse's responsibility to his or her patient, employer, society, or government? Privacy and confidentiality are concepts that could be challenged under the concept of fidelity. If a nurse is aware of another healthcare giver who is impaired, but the circumstances are private or confidential, how is the conflict resolved?
As a general rule, nurses are employed by a hospital, clinic, or private practice. Decisions that are made about patient care are not totally independent. Every decision creates a ripple effect and touches someone else in the health care field. One of the purposes of a code of ethics is to help nurses keep perspective and a balanced view regarding decisions. One way to study a code of ethics is to look at a case study.
J. L. presents herself to the emergency room with lower right abdominal pain. J. L. is a 17-year-old white female and is accompanied by her mother. J. L.'s mother is a nurse and works in another department of the hospital. The mother signed all of J. L.'s admission paperwork and received the Patient Bill of Rights. Although J. L.'s pain does not seem severe enough for appendicitis, she does have a history of fever for 24 hours and her temperature in the hospital is 100.8°F (38°C). An ultrasound that did not show appendicitis had been done earlier in the day. She was told to report to emergency room if the fever rose. After J. L. reports her symptoms to both a nurse and a physician assistant, she is examined briefly by emergency department physician. The staff assumes that J. L.'s mother wants to stay in the room and does not seek the patient's permission. As a part of her history, J.L. informs them she is not sexually active and is on the second day of her menstrual cycle. The mother can tell by the tone of questioning that the staff does not believe J.L. is still a virgin. After a two-hour delay, including having to repeat the urinalysis because of a lost specimen, the emergency physician decides a pelvic exam needs to be done. The pelvic exam is traumatic for the patient, despite her mother's best efforts to calm her. J. L. is told in a condescending tone that the exam hurts because of her failure to relax. Following the exam, the physician tells J. L. and mother that her blood count is normal, the urinalysis was inconclusive because of menstrual blood, and the patient was uncooperative in giving a catheterized specimen.
J. L. and her mother were informed a pregnancy test was done, because the staff have experienced "immaculate conceptions" in their department. The only time that J. L. and her mother had contact with an RN during this time was when she was initially triaged and when the discharge instructions were handed to her mother. J. L. and her mother were sent home with instructions. Her pain subsided without treatment.
Although this case study is not one of life and death decision making, there were numerous violations of the patient's rights and of the nursing code of ethics. The patient's right to privacy was violated. It is questionable whether the patient (J. L.) ever saw the Patient's Bill of
Rights, since it was given to her mother. J. L. was sexually inactive and a virgin, so the question of nonmaleficence is raised by the traumatic pelvic exam. The question of abandonment is also raised due to lack of nursing attention. If J. L. had asked her mother to leave during the exams, could confidentiality have been breached by the mother the next day by checking the hospital computer for reports? The answer to all of the above questions is yes; areas of nursing code of ethics could have been broken. No one died, but there must be constant reeducation of staff regarding the importance of these issues.
In an attempt to keep the concept of ethical care in the forefront of nurses, physicians, and other healthcare worker's minds, hospitals have ethics committees or even an ethicist on staff. Special educational seminars may be offered or actual case studies reviewed. Some hospitals have protocols for requesting an ethics consult at the bedside. These type of consults are usually seen in ICU or trauma situations where ceasing life support is being discussed.
A new area of potential ethical dilemma was discussed in the July 2, 1999, Online Journal of Issues in Nursing. Silva and Ludwick discussed the pros and cons of interstate practice laws. As new laws are passed that allow more fluid movement of nurses between states, new issues of ethical behavior may arise. The initial reaction of most people in the health care field is that a nurse practices the same way everywhere, but there are subtle differences in the laws between states. For example, there are different definitions of minors and when minors can be emancipated to make their own decisions. Are there differences in state laws regarding patients with impaired decision-making capabilities? What if the nurse is not aware of the subtle differences in each state's law?
Communication technology such as the Internet is also complicating ethical issues. Do web sites that encourage patients to describe symptoms to on-line nurses expose too great a risk? What backup mechanisms are in place if a patient talking to a triage nurse gets disconnected or loses consciousness? How can there be assurances of confidentiality in a telenursing setting? Silva and Ludwick encouraged their readers to "be proactive and stimulate critical thinking about ethics and interstate practice."
A nursing code of ethics cannot remain a stagnant document. As new issues arise in nursing and healthcare practice, they must be addressed and possibly included in a formal statement. The American Nurses Association (ANA) Code for Nurses with Interpretive Statements was approved in 1985 and was still being used in mid-2001. A task force met in 1996 and began the process of reviewing and revising the code. A draft of the new code is anticipated to be approved and released in 2001. The new code is more comprehensive than the 1985 code. It is the responsibility of all professional nurses to be aware of the Code for Nurses and any changes that may be made in the future. It is also the responsibility of each individual nurse to practice ethical care on a daily basis.
Beneficencehe obligation to do good, not harm, to other people.
Ethics specific area of study of morality, which concentrates on conduct and human values.
Maleficencehe act of intentionally doing harm or evil. Nonmaleficence is the principle of purposefully not doing harm.
Ellis, Janice R. and Celia L. Hartley. Nursing In Today's World: Challenges, Issues and Trends, 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins Publishing, 2001.
Silva, Mary C. and Ruth Ludwick. "Interstate Nursing Practice and Regulation: Ethical Issues for the 21st Century." Online Journal of Issues in Nursing July 1999. <<a href="http://www.nursingworld.org/ojin">http://www.nursingworld.org/ojin>.
American Nurses Association. 600 Maryland Ave. SW, Ste 100 West, Washington, DC 20024-2571. (800) 274- 4ANA. <<a href="http://www.nursingworld.org">http://www.nursingworld.org>.
"Florence Nightingale: Her Writings." 16 April 2001. <<a href="http://www.countryjoe.com/nightingale">http://www.countryjoe.com/nightingale>.
Gayle G. Wilkins, RN, BSN, OCN
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