ETHICS AND NURSING PRACTICE

The terms laws and ethics are distinct from one another, although some individuals mistakenly assume they mean the same thing. In the United States, law refers to any rule that, if broken, “subjects the person(s) who break the rule to criminal punishment or civil liability” (The Free Dictionary, n.d.a). Nurses must practice according to the laws that govern their society as well as their nursing practice.

Ethics refers to a system or set of moral principles that govern behavior, including job performance. Ethics includes beliefs about the “rightness” and “wrongness” of actions as well as the “goodness” and “badness” of motives and outcomes (The Free Dictionary, n.d.b). Nurses must practice according to the ethical principles of their profession.

Code of Ethics for Nurses

In addition to abiding by the laws established in the Nurse Practice Act, every member of a profession is expected to read, understand, and abide by the ethical standards of its occupation. In the case of nursing, the American Nurses Association (2015) publishes the Code of Ethics for Nurses with Interpretive Statements to guide nurses’ professional practice. The following provisions of the code broadly describe the ethical obligations of nurses:

Provision 1. The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.

Provision 2. The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.

Provision 3. The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.

Provision 4. The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care.

Provision 5. The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.

Provision 6. The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.

Provision 7. The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.

Provision 8. The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.

Provision 9. The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

Nursing Ethical Principles

Ethical principles are fundamental concepts by which people make decisions. Four ethical principles mark the practice of professional nursing and are inherent in the Code of Ethics for Nurses (Haddad & Geiger, 2020):

Autonomy is the belief that patients have the right to make their own decisions based on their own beliefs and values. For example, patients have the right to refuse treatment regardless of what benefit may come from it. Nurses must support autonomy.

Beneficence refers to a particular type of treatment. Nurses have a duty to abstain from maltreatment, minimize harm, and promote the good of the patient. This describes beneficence. For example, nurses have the responsibility to administer medications accurately, safely, and in a timely manner.

Justice means that all patients have the right to be treated fairly and equally. For example, patients who live in areas that do not have adequate healthcare services are not treated equally compared to those who are able to access (and afford) adequate treatment.

Nonmaleficence mandates that nurses do not cause harm to patients. This particular principle may be the most challenging to adhere to. For example, patients may refuse medication that is essential to their health and well-being. The patient has a right to refuse this medication, but the nurse is concerned that without the medication the patient may become dangerously ill, and even die. Nurses must ensure that patients have all of the information they need to make an informed decision. Even with such information, the patient may decide to refuse the medication, and the nurse must support the patient’s decision (autonomy).

Ethical Dilemmas

An ethical dilemma is a conflict between choices that, no matter what choice is made, some ethical principle will be compromised. Resolution of ethical dilemmas requires careful evaluation of all the facts of a case, including applicable laws, consultation with all concerned parties, and appraisal of the decision makers’ ethical philosophies (Hegde, 2019).

In order to resolve an ethical dilemma in the best possible way, several steps should be taken. These include:

  1. Gather all relevant data; include all options and opinions.
  2. Identify the existence of an ethical issue. Such issues typically occur when dealing with right versus wrong and good versus bad concepts.
  3. Identify the person(s) involved in the dilemma, their concerns, conflicts, and how they will be affected by decisions made.
  4. Identify all options for the resolution of the ethical dilemma.
  5. Analyze options and determine what solutions best facilitate resolution.
  6. Determine a course of action.
  7. Review how the involved persons feel about the proposed course of action.
  8. Take action.
    (Mintz, 2019)
ADVANCE CARE PLANNING

To reduce the number and complexity of ethical dilemmas, and in support of the ethical principle of autonomy, the Joint Commission (2015) recommends that all adults discuss their wishes regarding extraordinary treatment measures with their families, sign a legal document called an advance directive, and appoint someone to make healthcare decisions in their stead if they should become incapacitated (i.e., healthcare proxy).

CASE

A patient with metastatic breast cancer has decided to stop chemotherapy and wants simply to be made “as comfortable as possible.” She tells her healthcare team that the side effects of treatment are unbearable and that it is time to take back control of her life. The patient is 79 years old.

The patient’s family members, however, are adamant that she continue her treatment. They explain to the patient’s healthcare provider that she has been showing signs of dementia and “doesn’t really know what she wants.” The patient does not have a living will and has given one of her children power of attorney.

This situation can cause a significant ethical dilemma. Questions to ask include:

  • Is the patient legally competent?
  • What rights do family members have regarding their loved one’s care?
  • What are the potential consequences of stopping treatment?
  • What are the consequences of continuing treatment?

Laws and Rules

Laws flow from ethical principles and are limited to specific situations and codified by detailed language. Laws establish rules of conduct and are formulated by an authority with power to enforce them. As such, laws change with time and circumstances.

The state of Florida has the power to create and enforce laws governing the profession of nursing, including licensure. In the states, the division of power mirrors that of the federal government:

  • The legislative branch makes laws on behalf of the people.
  • The judicial branch interprets these laws and adjudicates disputes, fulfilling its purpose to administer justice without partiality.
  • The executive branch administers and enforces the laws, using the police power of the state.
SOURCES OF FLORIDA NURSING LAWS
  Statutory Administrative
Source Laws passed by legislative bodies of federal, state, and local governments Executive powers, delegated by the legislative branch
Functions Protects and provides for the general welfare of society Carries out special duties of various agencies
Example The Florida legislature passed the Nurse Practice Act, which is outlined in the Florida Statutes, Title XXXII, Chapter 464, Regulation of Professions and Occupations The Florida Department of State maintains statewide rules for nurses, which are outlined in the Florida Administrative Code, Division 64B9, Board of Nursing