Helping nurses make ethical decisions

By Tesfamicael Ghebrehiwet | 09/02/2005

Making ethical life and death decisions in providing care

Nurses and other health care providers are constantly challenged to make ethical decisions about life and death issues in providing care to individuals, families and communities. To be relevant and ethical, these decisions need to be considered in the broader context of personal, societal, cultural and professional values and ethical principles (Fry & Johnstone, 2002).

The nursing profession uses regulatory mechanisms, codes of ethics and other means to ensure ethical behavior. For example, The ICN Code of Ethics for Nurses asserts, “Inherent in nursing is respect for human rights, including the right to life, to dignity and to be treated with respect” (ICN, 2000, p. 2).

TesfaTo locate ethical issues within the context of nursing, it is vital to understand the International Council of Nurses (ICN) definition of nursing itself: “Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled, and dying people. Advocacy, promotion of a safe environment, research, participating in shaping health policy and in patient and health systems management, and education are also key nursing roles” (ICN, 2005).

This definition incorporates the three components of bioethics as outlined by Fry and Johnstone (2002), including norms of nursing practice, expansion of knowledge, and advocacy or policy development. It follows that nurses must develop a thorough knowledge of ethical issues, policies and procedures related to the protection of people as part of their responsibility as professional nurses.

Ethics and nursing responsibilities
As medical and scientific technology advance, individuals and society face dilemmas and difficult ethical decisions. Nurses, as part of society and as frontline health care professionals, daily face ethical dilemmas related to life and death and equity in health care. These include:

  • The right to health and access to health care
  • End-of-life issues such as euthanasia and extending life
  • Quality of life for people with terminal illness
  • Cloning and reproduction

 While these issues continue to attract public attention, they present nurses and other health care providers with real ethical dilemmas in their clinical practices and professional responsibilities. The ICN Code of Ethics for Nurses (2000) affirms that nurses have four fundamental responsibilities:

  • Promoting health
  • Preventing illness
  • Restoring health
  • Alleviating suffering

 As Fry and Johnstone (2002) have indicated, a nurse’s professional responsibilities can result in ethical conflict. Nurses’ responsibility to promote health is related to the basic right to health care enshrined in the constitutions of governments, the World Health Organization and the position statements of the International Council of Nurses. Yet, ethical questions often arise when promoting health. For example, providing contraceptive information to a woman whose religious beliefs disapprove their use can test the nurse’s ability to promote health.

Nursing responsibility in disease prevention is supported by ethical concepts of advocacy and caring, but that responsibility can conflict with ethical principles of privacy and confidentiality. For example, a nurse who is aware of a man who refuses to tell his partner of his HIV-positive status faces an ethical dilemma, as disclosing this information without his approval may constitute a breach of confidentiality. On the other hand, failure to disclose that information can lead to HIV infection of the partner.

In alleviating human suffering, there is a thin line between pain management and assisting death in terminally ill and dying patients. Similarly, in restoring health, what is the role of the nurse in administering a blood transfusion to a Jehovah’s Witness who refuses this procedure on religious grounds? While the responsibilities of the nurse seem clear, nursing decision-making is complicated by the complexity of these ethical issues.

Nurses and other health professionals often suffer from a “dual loyalty complex” (DLC) resulting from problematic ethical and human rights issues. This might arise from competing loyalties between the interests of patients and employers and can occur either willingly or under pressure (Myser, 2000). For example, nurses working in prison services can face dual loyalty. While the primary responsibility of a nurse is the health care of prisoners, prison authorities may coerce the nurse to assume the role of a prison guard.

The ICN Code of Ethics for Nurses provides a clear resolution of this dual loyalty when it states: “The nurse’s primary professional responsibility is to people requiring nursing care” (ICN, 2000, p. 2). Also, the ICN position statement “Nurses’ Role in the Care of Prisoners and Detainees” affirms that “nurses employed in prison health services do not assume functions of prison security personnel, such as body searches conducted for the purpose of prison security” (ICN, revised 2005).

The debate around euthanasia, assisted suicide and right to die continues unabated. While some argue that euthanasia should be permissible on grounds of the ethical principle of autonomy (Sullivan, 2001), others assert that facilitating euthanasia is incompatible with the fundamental role of a health care provider, especially the nurse (Zimbelman & White, 1999). As the law lords of the House of Lords in the United Kingdom put it, “Human rights were aimed at protecting the right to live with dignity, not a right to die with dignity” (Hopps, 2001).

The ethical dilemmas faced by nurses and others are complex, and they need direction in making ethics-related decisions. The ethical analysis and decision-making process outlined in the ICN textbook Ethics in Nursing Practice: A Guide to Ethical Decision Making (Fry & Johnstone, 2002) aim to do just that.

ICN code of ethics
As the worldwide voice of nurses and nursing, the International Council of Nurses has provided leadership with regard to ethical issues since its founding in 1899. As early as the 1930s, ICN established the Ethics of Nursing Committee to identify ethical problems encountered by nurses. Although the committee’s work was interrupted by World War II, an international code of ethics for nurses was established in 1953. Since then, the code has been revised and updated.

The ICN Code of Ethics for Nurses is a fundamental document that aims to ground nursing actions in ethical principles. Laying the foundation for ethical behavior of nurses in all roles—including clinician, teacher, manager and researcher—the code begins by highlighting the nurse’s role:

“Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health and to alleviate suffering. The need for nursing is universal. ... Nursing care is unrestricted by considerations of age, color, creed, culture, disability or illness, gender, nationality, politics, race or social status” (ICN, 2000, p. 2).

The ICN ethics code has been translated into some 20 languages and continues to serve in lieu of national codes and as an international reference. In fact, most national codes of ethics for nurses are based on The ICN Code of Ethics for Nurses. Recently, the ICN code for nurses has been adapted for use by nurses affiliated with the International Federation of Red Cross and Red Crescent Societies.

The ICN Code of Ethics for Nurses was revised in 2000 and has been widely disseminated throughout the world. Another revision is scheduled for release later this year.

Issues such as mapping the human genome, cloning, euthanasia, access and equity in health care have brought ethical dilemmas to the forefront and have complicated nursing responsibilities in health promotion, disease prevention, care and treatment. The International Council of Nurses, its member national associations and other organizations continue to provide direction and leadership in ethical decision-making. In this way, they aim to ensure that nursing is grounded in ethical principles compatible with human dignity, quality of life and patient safety.

Tesfamicael Ghebrehiwet, RN, PhD, is consultant for nursing and health policy at the International Council of Nurses, located in Geneva, Switzerland.

Fry, S., & Johnstone, M.J. (2002). Ethics in nursing practice: A guide to ethical decision making (2nd ed.). International Council of Nurses. Oxford, UK: Blackwell Science.

Hopps, J. (2001). British woman loses landmark right-to-die fight. Retrieved August 10, 2005.

International Council of Nurses. (1998). Nurses’ role in the care of prisoners and detainees. Position statement. Retrieved August 11, 2005.

International Council of Nurses. (2000). The ICN code of ethics for nurses. Geneva, Switzerland: Author.

Myser, C. (2000). The problem of dual loyalties: Standards of conduct for the health professionals. International Meeting, South Africa.

Sullivan, D. (2001). If autonomy is valuable, euthanasia should be permissible. British Medical Journal, 323, 1079-1108. Response to editorial. Retrieved November 10, 2004.

Zimbelman, J., & White, B.C. (1999) The moral appeal of assisted suicide in end-of-life decisions. Journal of Professional Nursing, 15(3), 142-145.

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