Chapter 1. Introduction to Ethics and Nursing

Introduction

This chapter will provide an overview of the duties of the nurse in routine practice, with a focus on ethical dimensions of care. The concept of ethics will be defined and clarified with respect to the nursing profession in order to highlight the importance of ethics for nurses. This is followed by a detailed discussion of the professional and legal frameworks that govern nursing practice in the UK, with an assessment on their ethical dimensions. The focus of this chapter will then be placed on the practical applications of ethical care and ethical processes in the nursing setting. This includes illustrations of how ethics can improve patient care and guide decision-making. The opportunities to reflect on your own practice throughout this chapter are intended to reinforce the value of ethics in nursing care, allowing you to improve your practice by adopting an ethical approach to patient interaction.

Learning objectives

By the end of the chapter, you should be able:

- To appreciate the importance of ethics in nursing

- To understand core ethical principles and apply these to practice

- To understand the importance of confidentiality

What are ethics in nursing?

Ethics is a branch of philosophy that is used to explore ideal forms of human behaviour and ideal ways of living. When applied to the healthcare setting, the purpose of ethics is to understand, analyse and distinguish behaviours and attitudes that are right or wrong (or good and bad) with respect to the wellbeing of patients (Butts & Rich, 2012). It is important to distinguish ethics from morals: ethics are concerned with right and wrong, while morals refer to actual behaviours and beliefs. Moral reasoning may be used to inform ethics in practice, but ethical judgements are generally agreed on by a wider body of individuals, eliminating the personal perspectives that may influence moral actions.

Ethical systems of care rely on a general agreement among professionals and laymen alike, whereby specific activities can be considered to be beneficial or detrimental to patient wellbeing (Benner et al., 2009). These systems are widely implemented throughout professional groups, including those in healthcare and law. Over time, a number of ethical theories have been devised in order to provide a framework for how professionals should act towards clients or service users. From these theories, ethical principles have developed which serve to specifically guide judgements on how to care for patients, from a nursing perspective.

What are nursing ethics?

Although ethics are clearly defined in the philosophical literature, applying ethics to the nursing profession demands a more focused discussion. Ethics are used as a basis to inform decision-making in situations where people may be placed at harm, or consequences to the individual or wider society may be negative (NMC Code, 2015). As a nurse, all decisions should take into account the need for ethical treatment of an individual, weighing up multiple factors of care and the consequences of care. However, ethics is a complicated field and not all decisions are easily categorised as 'good' or 'bad' for patients. Ethical dilemmas are commonly seen in nursing practice, where a decision to treat a patient may be associated with potential benefits and risks (Ulrich et al., 2010). Weighing up the benefits to the patient and the potential risks is a process that should be guided by an ethical framework, or set of principles. Nurses therefore have to understand how ethical principles apply to specific episodes of patient care in order to ensure that they act in accordance with the professional values and expectations of their role (NMC Code, 2015).

The use of ethics to justify a particular decision can be objective or relative, depending on the extent to which good and bad aspects of the decision are present. Objective ethical reasoning implies that a situation has a clear right or wrong course, making the decision-making process more straightforward. In such situations, all individuals would reasonably share the same ethical perspective. For instance, the decision of whether or not to administer emergency care to a patient in need is often considered an objective ethical scenario. However, part of understanding ethics is balancing the potential positive and negative effects of a course of treatment. Relativism in ethical judgements is often a more common course in nursing practice, where there may be pros and cons associated with an action (Butts & Rich, 2012). Numerous examples can be seen in practice, including the use of warfarin in patients with atrial fibrillation- warfarin helps to prevent blood clots and stroke, but is associated with many complications and a risk of bleeding. Balancing the risks and benefits of a treatment course and implementing suitable precautionary measures (for example, routinely monitoring anticoagulation with warfarin therapy) are vital to ensure the ethical treatment of patients.

Reflection

If you are undertaking a clinical placement as part of your studies, or have experience on the ward, take this opportunity to consider a patient you may have encountered. What ethical issues can you identify in relation to their care? How were these ethical issues resolved, if at all? What could be done to reduce ethical concerns in that situation in the future?

What are the core ethical principles of nursing practice?

Ethics is a broad discipline and it can be challenging to appreciate how ethics influences nursing practice. A number of core ethical principles have been recognised in the healthcare setting, applying to medical and nursing practice equally (Butts & Rich, 2012). These principles have developed over centuries and are intended to provide a basis for complex decision-making by weighing up multiple factors and consequences of the care process. The number of core principles varies, depending on the ethical framework used to inform practice, however it is generally recognised that four key principles apply to nursing practice: non-maleficence, beneficence, autonomy, and justice (Beauchamp & Childress, 2001).

Non-maleficence

Non-maleficence is a term that means 'do no harm' - an important consideration for all healthcare staff. Any action that is undertaken should not cause unnecessary harm or suffering to the patient and should be justified on the basis of ethical and professional judgement and guidance. This includes the need to avoid physical and psychological harm, both of which can have a detrimental impact on patient wellbeing. Evidence-based practice is a vital component of non-maleficence, as using research and evidence to inform treatment options and care decisions can minimise the risk of harm to the patient. It is vital that nurses are able to appraise the risk to the individual patient, based on patient-specific factors, and use interventions and treatments to minimise risk and maximise benefits.

Examples of non-maleficence would be stopping a medication that is causing harmful side effects to the patient or discontinuing a treatment strategy that is not effective and may be harmful to the patient.

Beneficence

Beneficence is a term that means 'do good', and covers actions that are performed in order to benefit the patient. As a nurse, your primary concern is supporting patients during their healing and recovery processes. Any interventions performed should be used to promote wellbeing and health in patients, including both physical and psychological outcomes. This applies to all care processes, including administering medication and providing patients with information and education. There is often a need to balance the potential for a treatment to do good and do harm, particularly when administering drugs with side effects, or in patients with complex care needs. Balancing non-maleficence and beneficence is an important part of nursing and requires careful consideration of other ethical principles.

Beneficence can be seen in multiple examples in the practice setting and includes the use of vaccines for the general population, providing patients with health advice and counselling, and providing emergency care to a patient.

Autonomy

The principle of autonomy reflects the idea that patients should be able to act independently and should be in control of their fate. Patients should be able to make decisions regarding their care or act intentionally in any way based on their understanding of events and their personal desires, without being controlled or excessively coerced by other people. That is not to say that nurses shouldn't try to influence patients to adopt a particular treatment strategy when that is the strategy with the strongest evidence base. However, nurses should not try to rob patients of the opportunity to make their own decisions, or influence them to adopt one course of action based on other factors. Preserving autonomy in patients can be achieved by using patient-centred care and involving patients in their own care decisions.

An example of behaviours that promote autonomy is presenting all treatment options to a patient and providing them with sufficient information such that the patient can make an informed choice in concert with medical advice.

Justice

The term 'justice' can be considered an obligation to act in a manner considered equitable, fair and consistent with the rights of the individual (Royal College of Nursing, 2012). Justice is therefore a key principle that ensures consistency and fairness in the treatment of all patients, regardless of their background or condition. All patients have the right to be treated equally and should not be discriminated against based on their personal characteristics, beliefs or values. Every patient has the right to be treated in a professional and ethical manner and nurses are important guardians of this right.

Examples of justice in practice include offering the same treatment options to two patients, even where one may have a condition through no fault of their own and the other through personal behaviour (e.g. lung cancer and smoking), and allocating resources equal among members of the population (e.g. vaccinations).

Other ethical principles

Although the four core ethical principles of nursing practice cover a broad range of activities, other ethical principles should also be considered important to ensure optimal practice. One principle is fidelity, which stands for dedication, advocacy and truthfulness towards patients and other professionals (MacDonald, 2007). Nurses should always be truthful to patients and should never attempt to deceive or manipulate patients in order to coerce them into a specific activity or treatment course. Fidelity also represents the need to maintain the confidence of the patient and to honour any commitments made to the patient. For instance, fidelity may apply to the scenario where a patient asks a nurse to withhold a terminal diagnosis from his or her family. The patient may feel that family members are unlikely to respect his or her wishes, seeking to prolong life at any cost. In this instance, the nurse should recognise the need to maintain confidential information for the patient, while also supporting the family in any way possible.

Totality and integrity are additional ethical principles that should be considered in complex decision-making circumstances. Totality and integrity suggest that the entire patient should be considered when deciding on a treatment course or intervention. This is of particular importance where serious side effects may be associated with that treatment, despite the potential to relieve certain symptoms or alter the management course. Indeed, not all actions can be considered in terms of beneficence or non-maleficence, as many treatments may lead to adverse effects despite their effectiveness in other areas. Nurses need to balance the risks and benefits of the intervention in a holistic manner in order to justify the use of such interventions in a proportional manner.

Reflection

This section highlights the multitude of ethical perspectives that should inform nursing care. Think back to the most recent patient you have seen in practice and consider your role in the ethical care of that patient. Did the principles of non-maleficence, beneficence, autonomy or justice apply to this patient?

Consider making a list of clinical care examples that reflect each of the four core principles of ethics in nursing, drawing from your own experiences. When you review these examples, consider how you can draw on your own personal perspectives to inform ethical practice. 

The NMC code and nursing practice

The Nursing and Midwifery Council (NMC) is a key professional body that play an important role in determining the professional and ethical values of the nursing profession. The NMC Code (2015) outlines these principles, covering not only the ethical requirements of the nurse, but also the professional and personal duties of nurses in the UK. The Code is therefore a comprehensive set of professional standards that nurses must adopt in order to be registered to practise in the UK.

From an ethical perspective, the NMC Code (2015) focuses on the need for nurses to be proficient in knowledge, skills and conduct. Ethical patient management can only be achieved by meeting all of the professional demands of the profession. The Code serves as a key guideline for ethical patient management, with consideration of the core ethical principles of non-maleficence, beneficence, autonomy and justice. It also extends the application of ethics to other roles of the nurse, including as an educator, leader or researcher. The NMC Code and its implications for nursing practice are considered in greater detail in Chapter 2. 

Reflection

Obtain a copy of the NMC Code (2015), either in print or online. Review the document and highlight ethical issues or principles that features within the guidelines, focusing specific on the four main ethical principles.

- Do you think that these ethical principles play a large role in the code of conduct for nurses and midwives?

- What ethical issues have you encountered in your own practice or training?

- How do you think the NMC Code will guide you in making ethical decisions?

How does UK law influence nursing obligations?

In addition to professional codes of conduct, as published by the NMC, UK law also influences the actions of nurses. Although it may seem unnecessary to understand the law when you want to devote your time to patient care, the reality is that law is now a fundamental part of nursing that underlies the relationship between you and your patient. Nurses have an obligation to adhere to legal frameworks and legislation when engaging in patient care and associated activities. As stated in the NMC Code, "you must always act lawfully, whether those laws relate to your professional practice or personal life".

The term 'law' can be defined as, "a rule enacted or customary in a community and recognised as commanding or forbidding certain actions" (Griffith & Tengnah, 2014, p.7). When applied to healthcare, the term is therefore related to the rules that determine the minimum standard of acceptable care you can deliver to a patient. In reality, patients deserve the highest level of care that can be delivered and therefore the standard required for the nursing profession is higher than expected by law. However, laws are important, in that they define instances where legal obligations to a patient group are broken, allowing for the use of sanctions.

Laws may also be fundamental in addressing complex care situations where ethical and professional obligations may conflict with wider societal views or interpretations (Dimond, 2008). An example might be the use of law surrounding end-of-life care and the practice of euthanasia. From an ethical or professional perspective, nursing staff may be conflicted over the use of interventions designed to end the life of a patient, as this action may relieve suffering. However, legal decisions provide clear guidance on the limitations of individual judgement in contrast to national law, providing a framework whereby such actions are deemed inappropriate and illegal. The law in this instance provides protection against the intentional use of medications or interventions to end the life of the patient.

As a nurse, it is vital that you are aware of the need to act according to UK laws and legislation. Specific legislation in the UK emphasises the role of law in guiding patient interactions, including the need for consent, respect of human rights and the appropriate use of medications. According to the law, competent adults always have a right to determine what is done to them, including any healthcare intervention, examination or associated process. In principle, nurses who do not seek consent before acting may be liable under criminal law and can be prosecuted. In reality this is not common, but the laying on of hands without consent may lead to civil lawsuits against the nurse or the organisation for which they work. Touching a patient without their permission can constitute battery, assault or negligence; it is important to adhere to the legal framework of consent when engaging in any form of patient care (Dimond, 2008). Human rights are also protected under a legal framework and nurses should act to ensure these rights are upheld at all times. The legal and ethical principles of care overlap a great deal with human rights, but it is important to remember that acting without considering human rights may lead to professional disciplinary action, as well as legal action.

Reflection

The role of law in UK nursing is of paramount importance and consent is one of the most important aspects of the law, along with the need to respect basic human rights. As an exercise, consider the management of a patient with a complex illness who needs to be treated in order to recover, but is refusing to give consent for the treatment.

- What are the legal implications of this scenario?

- Does the patient always have a right to refuse treatment?

- How should you act in order to meet your ethical obligations for care, without breaking the law?

Maintaining patient confidentiality

Confidentiality is a fundamental principle in healthcare, and it is important for nurses to understand how confidentiality is defined and how this applies to their practice setting (UK Clinical Ethics Network, 2011). Confidentiality is defined as the practice of restricting the sharing of sensitive patient information and only sharing information when it is necessary either by law or professional duty. Patients have a right to confidentiality and should be allowed to choose when their information is shared with others. Therefore, nurses need to respect the wishes of patients and seek their permission before sharing potentially sensitive information.

The types of information that can be considered confidential are varied in the healthcare setting. From a practical perspective, sharing any details of the patient's condition, treatment or personal life with other patients or family members is considered unethical (Department of Health, 2003). This includes the patient's name, date of birth, medical history, or any details that may be used to identify the patient in a given population. When discussing specific care details with the patient, any information exchanged or personal details shared are subject to confidential treatment. This is true even where the family members of the patient may have an interest in the details that the patient has shared. For instance, if a patient admits to substance abuse but does not wish their family to know, the nurse is obliged to maintain confidentiality.

As well as maintaining confidentiality in conversations with others, documentation needs to uphold the principle of confidentiality. Discussing patient details in public settings or outside of the ward or office, even with another healthcare professional, is generally not advised, as others may be listening to that information. When transporting or handling patient notes or sensitive documentation, care must be taken to ensure these documents are not lost or left in areas where they can be viewed by other patients or members of the general public. When sharing information in the research setting or during conferences, removal of patient identifiable information is essential and consent from the patient advisable (Department of Health, 2003).

The need to maintain confidentiality is complex and it is not always possible, or ethical, to withhold information from other parties when engaging in patient care. For instance, when the patient poses a risk of severe harm to him or herself or others, the nurse may be obliged to share confidential information with members of law enforcement or associated professionals. Similarly, if the patient reveals medical information that may place others at risk, it is the duty of the nurse to consider his or her ethical obligation to protect the rights of the patient, balanced with the rights of others or society in general. Ethical decision-making therefore can play a big role in maintaining confidentiality in practice.

Reflection

Think of a time when you have been on the ward or in practice and may have heard colleagues discussing the care of a patient.

- Was the conversation conducted in a confidential manner?

- What sorts of information can and cannot be shared when discussing patient care with others?

Conclusion

Overall, this chapter introduces the role of the nurse and the ethics of nursing in contemporary practice. Ethics is an important issue that affect all areas of nursing practice, and it is not always straightforward to decide if one management option is definitely without risk to the patient. As a result, ethical judgements need to be made based on the best available evidence, with respect to the rights of the individual, and through careful balancing of risks and benefits. It is important not to be overwhelmed by ethics when applying them to practice - in many cases, there are no right or wrong answers. Provided that you consider the ethics of patient care during any decision-making process, the outcome is likely to be a fair and effective course of action. When in doubt, it is important to consult colleagues and senior staff members who may have encountered specific scenarios before, or who are able to offer a different perspective on an ethical dilemma.

Reflection

Now that we have reached the end of this introductory chapter, you should:

- Have an appreciation of the importance of ethics in nursing practice

- Be able to identify core ethical standards from a nursing perspective

- Be able to recognise the importance of maintaining patient confidentiality.

Reference list

Beauchamp, T. L., & Childress, J. F. (2001). Principles of biomedical ethics. New York: Oxford University Press, USA.

Benner, P. E., Tanner, C. A., & Chesla, C. A. (2009). Expertise in nursing practice: Caring, clinical judgment, and ethics. London: Springer Publishing Company.

Butts, J.B., & Rich, K.L., (2012). Nursing ethics. New York: Jones & Bartlett Publishers.

Department of Health (2003). Confidentiality: NHS Code of Practice. London: DoH

Dimond, B. (2008). Legal aspects of nursing. London: Longman

Griffith, R., & Tengnah, C. (2014). Law and professional issues in nursing. Dorchester: Learning Matters (SAGE).

MacDonald, H. (2007). Relational ethics and advocacy in nursing: literature review. Journal of Advanced Nursing, 57(2), 119-126.

Nursing and Midwifery Council (2015). The code: professional standards or practice and behaviour for nurses and midwives. London: NMC

Royal College of Nursing (2012). Human rights and nursing. London: RCN

UK Clinical Ethics Network (2011). Ethical issues- confidentiality. Available at: http://www.ukcen.net/ethical_issues/confidentiality/professional_guidance [accessed 6th November 2016]

Ulrich, C. M., Taylor, C., Soeken, K., O'Donnell, P., Farrar, A., Danis, M., & Grady, C. (2010). Everyday ethics: ethical issues and stress in nursing practice. Journal of Advanced Nursing, 66(11), 2510-2519.