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Chapter 1. Introduction to Ethics and Nursing

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?

Ethics is a branch of philosophy that explores ideal forms of human behaviour. In healthcare, the purpose of ethics is to understand, analyse and distinguish behaviours and attitudes that are right or wrong (or good and bad). It is important to distinguish ethics from morals: ethics are concerned with right and wrong, while morals refer to individual 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 whereby specific activities are considered to be beneficial or detrimental to patient wellbeing. Ethical theories provide a framework for interactions with clients or service users. From these theories, ethical principles have developed to guide judgements on how to care for patients.

What are nursing ethics?

Ethical dilemmas are commonly seen in nursing practice, where a decision to treat a patient may be associated with potential benefits and risks. Weighing up these up should be guided by an ethical framework or set of principles. Nurses should understand how ethical principles apply to practice, to ensure that they comply with the professional values and expectations of their role.

Application of ethics can be objective or relative, depending. Objective ethical reasoning implies that a situation has a clear right or wrong course, such as the decision to administer emergency care to a patient in need. However, it is important to balance the potential positive and negative effects of a course of treatment. Relativism in ethical judgements is common in nursing practice, where there may be pros and cons associated with an action. Examples include the use of warfarin in patients with atrial fibrillation- warfarin helps 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 are vital to ensure the ethical treatment of patients.

What are the core ethical principles of nursing practice?

A number of core ethical principles are recognised in the healthcare setting. These provide a basis for complex decision-making by weighing up multiple factors and consequences of the care process. The number of core principles varies; however, four key principles are generally recognised: non-maleficence, beneficence, autonomy, and justice.

Non-maleficence

Non-maleficence means 'do no harm'. Any action should not cause unnecessary harm or suffering to the patient and should be justified by ethical and professional judgement and guidance. This includes both physical and psychological harm. Evidence-based practice is vital, as it can minimise the risk of harm. Nurses must be able to appraise the risk to the individual, and use interventions and treatments to minimise risk and maximise benefits.

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

Beneficence

Beneficence means 'do good', and promotes actions that benefit the patient. Nurses should support patients during their healing and recovery. 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 important, and requires careful consideration.

Beneficence can be frequently seen in practice, and includes the use of vaccines, providing patients with health advice and counselling, and providing emergency care.

Autonomy

Autonomy states that patients should be able to act independently and should be in control of their fate. Patients should make decisions regarding their care or act intentionally, without being controlled or excessively coerced. Nurses may try to influence patients to adopt a particular treatment strategy when that is the strategy with the strongest evidence base, but must not prevent patients making their own decisions. Preserving autonomy for patients can be achieved through 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

'Justice' entails obligations to act in a manner considered equitable, fair and consistent with the rights of the individual. Justice ensures fairness in the treatment of all patients; they have the right to be treated equally, regardless of their background or condition, and should not be discriminated against based on personal characteristics, beliefs or values.

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 equally among members of the population.

Other ethical principles

Other ethical principles should also be considered. One is fidelity, which stands for dedication, advocacy and truthfulness towards patients and other professionals. Nurses should never attempt to deceive or manipulate patients, and should maintain the confidence of the patient and honour any commitments made. For instance, fidelity applies in a scenario where a patient asks a nurse to withhold a terminal diagnosis from their family. In this instance, the nurse should recognise the need to maintain confidential information for the patient, while also supporting the family.

Totality and integrity are additional ethical principles. Totality and integrity suggest that the entire patient should be considered when planning care. This is important where serious side effects may be associated with a treatment, despite the potential to relieve certain symptoms or alter the management course. 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 to justify their use.

The NMC code and nursing practice

The Nursing and Midwifery Council (NMC) is a key professional body that helps determine the professional and ethical values of the profession. The NMC Code covers the ethical requirements and also the professional and personal duties of nurses in the UK. Nurses must adopt the Code in order to be registered to practise in the UK.

The NMC Code 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 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. This is covered in greater detail in Chapter 2. 

How does UK law influence nursing obligations?

The law is 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 etc.

In healthcare, law is 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 define instances where legal obligations to a patient group are broken, allowing for the use of sanctions.

Laws may help in addressing complex care situations where ethical and professional obligations may conflict with wider societal views. Examples include the laws surrounding end-of-life care and euthanasia. 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, the law provides clear guidance on the limitations of individual judgement in contrast to national law; such actions are deemed inappropriate and illegal. The law prohibits the intentional use of medications or interventions to end the life of the patient.

Nurses must comply with UK laws and legislation. Legislation emphasises the role of law in guiding patient interactions, including the need for consent, respect of human rights and use of medications. Competent adults always have a right to determine what is done to them, including any healthcare intervention, examination or associated process. Nurses who do not seek consent before acting may be liable under criminal law and can be prosecuted. This is uncommon, but the laying on of hands without consent may lead to civil lawsuits against the nurse or their place of work; it is important to adhere to the legal framework of consent. Human rights are also protected under a legal framework and nurses should act to ensure these rights are upheld at all times. Acting without considering human rights may lead to professional disciplinary action, as well as legal action.

Maintaining patient confidentiality

Confidentiality is a fundamental principle in healthcare, and nurses must understand how this applies to their practice. Confidentiality pertains to restricting the sharing of sensitive patient information and only sharing information when it is necessary either by law or professional duty. Patients 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.

Many types of healthcare information are considered confidential. Sharing details of the patient's condition, treatment or personal life with other patients or family members is considered unethical. When discussing 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 information; for instance, if a patient admits to substance abuse but does not wish their family to know.

As well as maintaining confidentiality in conversations with others, documentation needs to uphold the principle of confidentiality. Discussing patient details in public or outside of the ward or office, even with another healthcare professional, is not advised, as others may be listening. When transporting or handling patient notes or sensitive documentation, care must be taken to ensure these documents are not lost or left 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 patient consent advisable.

Confidentiality is complex; 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.

Conclusion

This chapter introduces the role of the nurse and the ethics of nursing in contemporary practice. Ethics affects all areas of nursing practice, and it is not always straightforward to decide if one management option is definitely without risk to the patient. 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.