Ethical Principles in Nursing

Ethical Principles
How Ethics Applies to Nursing Practice

Ethics are incredibly important in nursing practice. It ensures that patients are being treated
in a correct manner. There’s a delicate balance between applying many of the principles,
such as beneficence and paternalism (Macciocchi, French, & Bush, 2009). Occasionally,
ethical boards must become involved in order to determine the best actions. Furthermore,
courts will have the final decision in cases that can’t be resolved through preliminary
means.

Core EthicalPrinciples in Nursing

 Autonomy
 Beneficence
 Fidelity
 Informedconsent
 Integrity
 Justice
 Nonmaleficence
 Paternalism
 Privacy and confidentiality
 Veracity

Ethical Theories that Influence Nursing Practice

 Consequentialism
 Deontology
 EthicalRelativism
 Utilitarianismtheory

Autonomy
WhatisAutonomy?

Autonomy refers to the patients’ rights to make self-governing decisions or self-determine a

course of action. In healthcare, this applies to the patient’s right to make decisions
about their own lives and health without interference from the nurse, physician, or other
team member. The nurse must respect the patient’s right to independent decision making.
This involves resisting the urge to interject one’s own feelings, vales, or beliefs onto the
patient. Infringement upon this right is unethical (American Nurses Association, 2011).

Autonomy was first brought to the public’s eye when the Patient Self Determination Act
was passed by Congress in 1990. This Act states that competent individuals are allowed to
make their own decisions pertaining to end of life care. It also outlined patients’ right to
appoint a durable power of attorney, which designates another individual the authority to
make end-of-life decisions when the individual is no longer able to do so themselves
(American Nurses Association, 2011).

Examples of ApplyingAutonomy

 The hospital maintains a supply of brochures in the lobby that

provides information on appointing a durable power of attorney
 The nursing staff of a dialysis clinic has been treating a patient with end-stage renal
disease for several years. One day, the patient informs them that this will be his last
visit, as he no longer wants to receive dialysis after being turned down for a kidney
transplant. The nurses realize that the patient is competent to make such decisions.
Although some of the nurses are emotionally distressed about his choice, they
understand that the patient has the right to decline treatment and respect the his
decision
 The staff of a genetic clinic practices a form of nondirective counseling, which is
commonly used in the field of genetics. The clinician or counselor provides
information to a couple that predicts the chances that they will have a child with a
genetic defect. While providing this information, they keep the conversation based
in facts, offering data on probability rates as requested, but do not attempt the direct
the patients’ decision making in any way. The right of the patients to make self-
governing decisions is respected

Beneficence
WhatisBeneficence?

 Beneficence refers to the act of doing what’s in the best interest of the patient (Silva
& Ludwick, 1999)
 Potential issues that may arise in relation to the concept of beneficence include
financial reimbursement of services are that approved by an insurance company,
mandatory reporting on certain communicable diseases, reporting abuse/neglect of
vulnerable patients, and facility protocols
 This involves taking actions to help benefit others and prevent both physical and
mental harm (Muthuswamy, 2011)

Potential Ethical Issues Related to Beneficence

 Financial reimbursement such as what services are approved by an insurance

 Mandatory reporting on certain diseases transmitted diseases
  Reporting abuse
 Facilityprotocols (Silva & Ludwick, 1999)

Fidelity
WhatisFidelity?

Fidelity is virtue that refers to integrity, which is achieved by the embodiment of loyalty,
fairness, truthfulness, advocacy, and dedication that is motivated by an underlying principle
of care. Nurses must encompass integrity in all that they do (American Nurses Association,
2011). The nurse practices fidelity by remaining committed and keeping promises.

Examples of ApplyingFidelity

 The nurse tells the patient that she will come back to check on her. Even though she
gets slammed by a heavy workload, she manages to squeeze in a few moments to
visit the patient
 A nurse is providing end-of-life care for a patient who is in pain. The nurse is
unable to obtain an order to pain drugs from the provider, who seems to have an
attitude that this issue is not worth her time to address. Understanding that he must
advocate for the patient, he approaches his supervisor to explain the issue.
Eventually, an order for morphine is received and the nurse is able to administer it
to the patient

Informed Consent
The Application of Informed Consent

Informed consent involves the patient’s right to autonomy and self-determination. Accurate
information must be provided to enable patients to make an informed decision about their
treatment (Daly, 2009). There are variations in how it is obtained from the individual; it
may be generally implied or expressed. Expressed consent can be obtained in either
a verbal or written methods (Lin & Chen, 2007). Performing a procedure without consent
can be construed as a battery or assault. Clinicians and nurses that feel that they know
what’s best and force their beliefs upon a patient are acting in a paternalistic manner. There
are three elements of informed consent.

The Three Elements of Informed Consent

 Informed
 Competent
 Voluntary

What it Means to be “Informed”

  The state of informed involves communication that facilitates an understanding of
a nursing/medical procedure or research process prior to having the patient
participate
 Sufficientinformationmust be provided

What it Means to be “Competent”

 The state of competency means that individual must have the mental capacity to
understand the implications of decisions
 This involves the capacity to weigh out the potential benefits in comparison to the
risks by applying “rational reason” (Macciocchi, French, & Bush, 2009)

What it Means to be “Voluntary”

 The state of voluntary means that the patient is not coerced into participation and
that consent can be withdrawn at any time
 This respects the patient’s right to autonomy

Justice
WhatisJustice?

 Justice refers to fairness and equality

 Justice is applied practically by providing equitable access to nursing care
 Need is the driving principle is when the allocation of resources are limited or
scarce
 Equitable access to nursing care requires that services be distributed fairly to those
in need
 When the allocation of resources that are limited or scarce, the driving principle is
need

Nonmaleficence
WhatisNonmaleficence?

 Nonmaleficence means to “do no harm.”

 This concept originated from the Hippocratic Oath
 It’s applied practically to nursing by not causing injury, weather it be physical,
psychological, emotional, or financial injury to patients (Silva & Ludwick, 1999)
 Informed consent: obtaining consent for treatment from a patient that mentally and
cognitively able to provide such, following a process of teaching, including an
explanation of the potential benefits and risks, alternative options, and a reminder
that consent may be withdrawn at any time
 (Muthuswamy, 2011)
Paternalism
WhatisPaternalism?

Paternalism occurs when the nurse does not respect the patient’s right to autonomy by
acting as if he or she knows what’s best for the patient, rather than the patient (Silva
& Ludwick, 1999). Paternalism disempowers the patient. A nurse is being paternalistic by
acting as an authority to regulate needs by making decisions on behalf of a patient.

Examples of ActingPaternalistic

 The physician decides to that the patient needs to have a spiritual leader for a nearby
church visit him as he is dying. The patient refused to have a visit earlier as he
doesn’t have a religious faith. The physician’s actions are paternalistic as he
assumes that he can make decisions for the patient better than the patient can
himself

Privacy and Confidentiality

What is Privacy and Confidentiality?

Maintaining privacy and confidentiality involves only sharing patient information on a

need-to-know basis. Actions in healthcare delivery are structured and governed by HIPPA
law. The nurse must act to prevent breaches of confidentiality.

Examples of Applying Privacy and Confidentiality

 A person comes to the Med-Surg floor, claiming to be the patient’s wife. The nurse
checks the document that lists the individuals authorized to be privy to private
healthcare information. The patient’s wife is indeed listed on the document.
However, as the nurse has never seen the woman before, decides to ask for
identification prior to telling her his room number. Upon the request, the woman
suddenly becomes nervous and bails. The nurse later learns that the woman is not
the patient’s wife, but a scorned ex-girlfriend. The patient and his actual wife
had obtained a restraining order on her following several incidents of stalking and
harassment
 A nurse is working at an urban drug rehabilitation facility. Over the course of
several weeks, she has become close to a woman who is recovering for crack-
cocaine addiction. As her release date approaches, the woman becomes close to
another patient. She reveals to the nurse that the two are planning on “going
out”once they are released. stigmatizing and hence needs to be kept confidential

Veracity
What is Veracity?
Veracity is a dual concept that refers to both the duty to disclose pertinent information and
the obligation to respect confidentiality. For instance, a patient must be given the truth by
being informed of the risks involved in a treatment. On the other end, veracity also involves
respect for patient’s confidentiality. In line with the last example, the healthcare team is not
able to use the patient’s treatment outcomes in research without gaining permission first.

EthicalTheories
CommonEthicalTheories

 Consequentialism
 Deontology
 EthicalRelativism
 Utilitarianismtheory

UtilitarianismTheory

Utilitarianism was first proposed by Jeremy Bentham in the late 1700s. It postulates that
government interventions are useful only if they promote the greatest good for the greatest
number of people. An emphasis is placed on guiding actions by their usefulness and
evaluating them against the produced outcomes or consequences. This ethical theory is
observed through the age-based eligibility requirements of the Medicare system, which
provides equal access to its users (American Nurses Association, 2011).

Deontology

Deontology, an ethical theory founded by Immanuel Kant, applies judgments based on the
underlying morality, or the rightness or wrongness, of an action. It is based upon adherence
to rules. The driving factor of decisions are evaluated through the intentions rather than the
outcomes. Actions are classified into categories. Two of the most outstanding ones
include universal law of humanity (categorical imperative) and principle of ends, which
perceives that actions should be based in the end and never merely as a means (American
Nurses Association, 2011).

Ethical Relativism

Ethical relativism is a theory that is based in a doctrine that accounts for the variability in
what is considered to be acceptable behaviors are relative to the norms of a
given culture. The theory states that the decisions should be examined within the social
context in order to determine if the action is moral. Right and wrong is not definite in most
cases as there are no absolute truths. What may be tolerable for one culture is taboo for the
next. While there are no universal truths in ethical relativism, there are a few topics that are
not open to debate, such as incest (American Nurses Association, 2011).
 Resources for Nursing Students on Ethics

 American Nurses Association (2011). Short definitions of ethical principles,

theories and familiar words: What do they mean? ANA Ethics Advisory Board.
Retrieved from
http://www.nursingworld.org/MainMenuCategories/EthicsStandards/Resources/Ethi
cs-Definitions.pdf
 Aveyard, H. (2004). The patient who refuses nursing care. Journal of Medical
Ethics, 30(4), 346-350. Retrieved from http://jme.bmj.com/content/30/4/346.full
 Daly, B. (2009). Patient consent, the anaesthetic nurse and the peri-operative
environment: Irish law and informed consent. British Journal of Anaesthetic&
Recovery Nursing, 10(1), 3-10
consent. http://doras.dcu.ie/2445/1/british_jour_anaest_recov_nursing.pdf
 Epstein, E.G., & Delgado, S. (2010). Understanding and addressing moral distress.
The Online Journal of Issues in Nursing, 15(3). Retrieved from
http://www.nursingworld.org/MainMenuCategories/EthicsStandards/Courage-and-
Distress/Understanding-Moral-Distress.html
 Fouka, J., &Mantzorou, M. (2011). What are the major ethical issues in conducting
research? Is there a conflict between the research ethics and the nature of nursing?
Health Science Journal, 5(1), 3-14. Retrieved from
http://www.hsj.gr/volume5/issue1/512.pdf
 Lin, J. N., & Chen, K. M. (2007). Cultural issues and challenges of informed
consent in older adults. Chi Nursing Journal, 6(5), 65-72. Retrieved from
http://www.tzuchi.com.tw/file/DivIntro/nursing/content/200710-06-05en/6_5p65-
71.p
 Loveridge, N. (2000). Ethical implications of achieving pain management through
advocacy. Emergency Nurse, 8(3), 16-21. Retrieved from
http://rcnpublishing.com/doi/full/10.7748/en2000.06.8.3.16.c1322
 Macciocchi, S. N., French, L. N., & Bush, S. S. (2009). Ethical issue: Doing good:
The pitfalls of beneficence. Journal of Head Trauma Rehabilitation, 24(1), 72-74.
Retrieved from
http://www.nursingcenter.com/lnc/JournalArticle?Article_ID=840559
 Midwives Magazine (August, 2003). Critical incident analysis: informed consent
and the use of vaginal examinations during labour. The Royal College of Midwives.
Retrieved from http://www.rcm.org.uk/midwives/features/critical-incident-analysis-
informed-consent-and-the-use-of-vaginal-examinations-during-labour/
 Muthuswamy, V. (2011). Ethical issues in genetic counselling with special
reference to haemoglobinopathies. Indian Journal of Medical Research,134(4), 537-
540. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3237255
 Pavlovic, D., &Spassov, A. (2011). Asymmetries of patient autonomy and
paternalism. Journal of Clinical Research and Bioethics, 2(112). Retrieved from
http://www.omicsonline.org/2155-9627/2155-9627-2-112.php
 Silva, M. C., & Ludwick, R. (1999). Interstate nursing practice and regulation:
Ethical issues for the 21st Century. Online Journal of Issues in Nursing, 4(2).
Retrieved from
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 cals/OJIN/TableofContents/Volume41999/No2Sep1999/InterstateNursingPracticea
ndRegulation.html
 Sorrell, J. (2012). Ethics: The Patient Protection and Affordable Care Act: Ethical
perspectives in 21st Century health care. The Online Journal of Issues in Nursing,
18(1). Retrieved from
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cals/OJIN/Columns/Ethics/Patient-Protection-and-Affordable-Care-Act-Ethical-
Perspectives.html
 Verweij, M. (2002). Influenza vaccination rates and informed consent in Dutch
nursing homes: Survey of nursing home physicians. British Medical Journal, 324.
Retrieved from http://www.bmj.com/content/324/7333/328