Ethics in Professional Nursing Practice

Ethics in Professional Nursing Practice

Values in Nursing

Values emphasized in the Code of Ethics with Interpretive Statements (ANA, 2001)

Wholeness of character


Basic dignity

Personal dignity



Ethical Theories and Approaches

Virtue ethics

Natural law theory



Ethics of care

Ethical principlism



Ethical Principlism







Professional Ethics and Codes

The Nightingale Pledge (1893)

Nursing Ethics: For Hospital and Private Use (1900)

ICN’s Code of Ethics for Nurses (1953)

ANA’s Code of Ethics for Nurses (1950)



ANA’s Code of Ethics for Nurses

Nine provisions with interpretive statements containing specific guidelines for clinical practice, education, research, and administration

The code is considered to be nonnegotiable in regard to nursing practice



Examples of Themes in the Code of Ethics with Interpretive Statements

Respect for autonomy


Patients’ interests



Competent practice

Accountability and delegation



Environment and moral obligation

Contributions to the nursing profession

Human rights

Articulation of professional codes by organizations

The ICN Code of Ethics for Nurses

Nurses have 4 fundamental responsibilities:

To promote health

To prevent illness

To restore health

To alleviate suffering



Common Themes of ANA and ICN Codes

Focus on the importance of nurses delivering compassionate patient care aimed at alleviating suffering; patient is the central focus of nurses’ work.

Applies to all nurses in all settings and roles; nonnegotiable ethical nursing standards with a focus on social values, people, relationships, and professional ideals.

Share values of respect, privacy, equality, and advocacy.

Both codes illustrate idea of nurses’ moral self-respect.



Ethical Analysis and Decision Making in Nursing

Ethical dilemmas and conflicts

Moral suffering

Team approach

Case-based approach using 4 topics method

Medical indications

Patient preferences

Quality of life

Contextual features



Medical Indications

What is the patient’s medical problem? History? Diagnosis? Prognosis?

Is the problem acute? Chronic? Critical? Emergent? Reversible?

What are the goals of treatment?

What are the probabilities of success?

What are the plans in case of therapeutic failure?

In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?



Patient Preferences

Is the patient mentally capable and legally competent? Is there evidence of incapacity?

If competent, what is the patient stating about preferences for treatment?

Has the patient been informed of benefits and risks, understood this information, and given consent?

If incapacitated, who is the appropriate surrogate? Is the surrogate using appropriate standards for decision making?

Has the patient expressed prior preferences?

Is the patient unwilling or unable to cooperate with medical treatment? If so, why?



Quality of Life

What are the prospects, with or without treatment, for a return to normal life?

What physical, mental, and social deficits is the patient likely to experience if treatment succeeds?

Are there biases that might prejudice the provider’s evaluation of the patient’s quality of life?

Is the patient’s present or future condition such that his or her continued life might be judged undesirable?

Is there any plan and rationale to forgo treatment?

Are there plans for comfort and palliative care?



Contextual Features (1 of 2)

Are there family issues that might influence treatment decisions?

Are there provider (physicians and nurses) issues that might influence treatment decisions?

Are there financial and economic factors?

Are there religious and cultural factors?



Contextual Features (2 of 2)

Are there limits on confidentiality?

Are there problems of allocations or resources?

How does the law affect treatment decisions?

Is clinical research or teaching involved?

Is there any conflict of interest on the part of the providers or the institution?

Relationships and Professional Ethics

Nurse–physician relationships

Nurse–patient–family relationships

Unavoidable trust



Patient advocacy

Nurse–nurse relationships



The National Council of State Boards of Nursing’s Professional Boundaries in Nursing Video


Moral Rights and Autonomy (1 of 2)

Moral rights are defined as rights to perform certain activities.

Because they conform to accepted standards or ideas of a community

Because they will not harm, coerce, restrain, or infringe on the interests of others

Because there are good rational arguments in support of the value of such activities



Moral Rights and Autonomy (2 of 2)

Two types of moral rights

Welfare rights

Liberty rights

Informed consent

Patient Self-Determination Act

Advance directives

Living will

Durable power of attorney



Social Justice

Sicilian priest first used term in 1840; in 1848, popularized by Antonio Rosmini-Serbati

Center for Economic and Social Justice definition

John Rawls’s concept of veil of ignorance

Robert Nozick’s concepts of entitlement system

Allocation and Rationing of Healthcare Resources

Does every person have a right to health care?

How should resources be distributed so everyone receives a fair and equitable share of health care?

Should healthcare rationing ever be considered as an option in the face of scarce healthcare resources? If so, how?



Organ Transplant Ethical Issues

Moral acceptability of transplanting an organ from one person to another

Procurement of organs

Allocation of organs


Medical utility



Balanced Caring and Fairness Approach for Nurses (1 of 2)

Encourage patients and families to express their feelings and attitudes about ethical issues involving end-of-life, organ donation, and organ transplantation.

Support, listen, and maintain confidentiality with patients and families.

Assist in monitoring patients for organ needs.

Balanced Caring and Fairness Approach for Nurses (2 of 2)

Be continually mindful of inequalities and injustices in the healthcare system and how the nurse might help balance the care.

Assist in the care of patients undergoing surgery for organ transplant and donation patients and their families.

Provide educational programs for particular target populations at a broader community level.

Definitions of Death

Uniform Determination of Death Act definition of death: “An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions or (2) irreversible cessation of all functions of the entire brain, including the brain stem is dead. A determination of death must be made in accordance with accepted medical standards.”

Traditional, whole-brain, higher brain, personhood.




Types of euthanasia:

Active euthanasia

Passive euthanasia

Voluntary euthanasia

Nonvoluntary euthanasia

Blending of types may occur

“Is there a moral difference between actively killing and letting die?”



Rational Suicide


Categorized as voluntary active euthanasia

Person has made a reasoned choice of rational suicide, which seems to make sense to others at the time:

Realistic assessment of life circumstances

Free from severe emotional distress

Has motivation that would seem understandable to most uninvolved people within the community



Palliative Care

Approach that improves the quality of life of patients associated with life-threatening illness, through prevention and relief of suffering

Do-not-resuscitate order:

There is no medical benefit that can come from cardiopulmonary resuscitation (CPR).

The person has a very poor quality of life before CPR.

The person’s life after CPR is anticipated to be very poor.



Rule of Double Effect

Use of high doses of pain medication to lessen the chronic and intractable pain of terminally ill patients even if doing so hastens death

Critical aspects of the rule:

The act must be good or at lease morally neutral.

The agent must intend the good effect not the evil.

The evil effect must not be the means to the good effect.

There must be a proportionally grave reason to risk the evil effect.



Deciding for Others

A surrogate, or proxy, either is chosen by the patient, is court appointed, or has other authority to make decisions

Three types of surrogate decision makers:

Standard of substituted judgment

Pure autonomy standard

Best interest standard



Withholding and Withdrawing Treatment: 3 Cases

Case 1: Karen Ann Quinlan

Case 2: Nancy Cruzan

Case 3: Terri Schiavo



Terminal Sedation

“When a suffering patient is sedated to unconsciousness…the patient then dies of dehydration, starvation, or some other intervening complication, as all other life-sustaining interventions are withheld.”

Has been used in situations when patients need relief of pain to the point of unconsciousness.



Physician-Assisted Suicide

Act of providing a lethal dose of medication for the patient to self-administer

Oregon Nurses Association special guidelines related to the Death with Dignity Act

Maintaining support, comfort, and confidentiality.

Discussing end-of-life options with patient and family.

Being present for patient’s self-administration of medication and death.

Nurses may not administer the medication.

Nurses may not refuse care to the patient or breach confidentiality.



End-of-Life Decisions and Moral Conflicts with the Nurse

Communicating truthfully with patients about death due to fear of destroying all hope

Managing pain symptoms because of fear of hastening death

Feeling forced to collaborate relative to medical treatments that in the nurses’ opinion are futile or too burdensome

Feeling insecure and not adequately informed about reasons for treatment

Trying to maintain their own moral integrity


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