NURSING ETHICAL LEGAL CONSIDERATIONS IN TODAY’S PRACTICE
There is a growing amount of literature and media attention to ethical
issues. Every week on medical and legal television shows, such as "ER" and
"Law and Order," characters are faced with ethical dilemmas and decisions. In
reality, nurses are confronted with an increasing number of ethical decisions
within their practice everyday. With unparalleled technological advancement,
nursing and bio-medical research, and the present healthcare environment,
nurses must be cognisant of their professional and personal views of ethics.
In this essay, a view of the aims of bioethics and more specifically nursing
ethics will be explored. The influences of the present healthcare environment
and societal developments as they relate to nursing ethics will be addressed,
and some of the main ethical legal issues that have impacted recent practice
will be identified and examined.
Ethics comes from the ancient Greek word meaning character or customs. Within
each society, particular customs and norms develop. While a custom may be
sanctioned in one society or context, the custom may not be seen as right by
other cultures or societies (Bosek, 2001). Ethics suggests a code of
acceptable behaviour or practice and includes the study of social morality as
well as philosophical reflection on its norms and practices (Beauchamp and
Bioethics and nursing ethics may be considered in the same philosophical
realm but differ in both approach and application. Engelhardt (1986) views
bioethics as "the study of moral and conceptual problems associated with
healthcare and the biomedical sciences." Bioethics tends to be medico-centric
in nature and perspective (Johnston, 1999) with focus on identification of
ethical concerns in medical and scientific research.
This author agrees with Reich (1978) that the aim of bioethics is the
guidance of moral decision-making and discussion in medical science research
and study. Bioethics holds to the philosophy that human life must be
preserved at any cost, with "the medical ideology that prolonged life of any
quality is a prime value (Barnum, 1998). This is contrary to nursing’s
philosophy that the preservation of dignity and human rights should take
precedence over preservation of life, including the right to die without
The aim of nursing ethics.
Nursing ethics is not a subcategory of medical ethics, but separate with its
own literature, context and application (Veatch, 1985). Nursing ethics refers
to the "principles governing the conduct of nurses in relation to patients,
their families, associates, and society at large (Wlody, 1998). Johnstone
(1999) further describes nursing ethics as "a practice discipline, which aims
to provide guidance to nurses on how to decide and act morally in the
contexts in which they work.
Nurses have a unique association with patients, a "more direct and therefore
more ethically compelling relationship" (Loewy and Loewy, 2001). A recent
Gallop Poll ranked nurses above medical doctors, teachers, and even clergy
when asked which profession was regarded as "the most honest and ethical"
The aim of nursing ethics should be the examination of ethical issues
specific to nursing. This incorporates the protection of patient rights and
the deontological principles of autonomy, beneficence, nonmalfience, justice
and confidentiality, and offers practical guidance on decision-making in the
practice setting, regardless of individual ideologies.
Developments in society and healthcare effecting ethics and law.
There are significant developments in society and healthcare delivery that
influence this view of nursing ethics. With rapid technological advance and
the present healthcare environment, nurses must deal with an increased number
of new and complex ethical dilemmas. Sometimes these issues are previously
unknown and "at any given time the practitioner may be confronted with
particularities that are not yet accounted for in science or technology"
(Puntillo, Brenner, Drought, Drew, Stotts, Stannard, Rushton, Scanlon, and
Within society and healthcare delivery, the profession of nursing is advancing.
A professional code of ethics is an important hallmark of a profession
(Goldman, 1980). Acquiring a nursing licence does not ensure moral or ethical
practice. The American Nurses Association, in response to social and
healthcare needs, has developed a Code of Ethics. The Code articulates
nursing’s moral duties and obligations, but ultimately the nurse is
accountable to the laws of the land.
America has, potentially, the most medically litigious society. Recently in
the media, there have been enormous case settlements, such as those for
smokers, and, as a result, malpractice insurance costs have escalated.
Although nurses make ethically based decisions, they must also be aware of
the legal consequences. The laws of the land are still paramount and even
those decisions based on a professional ethical code may not be defendable in
court. Nurses are encouraged to "Chart for the Lawyer, not the Doctor".
The progression of managed health care, with attention on cost containment
and efficiency, has noticeably influenced patient care. The development of
health management organizations, and for-profit centres has led to
restrictions on patient access to care and even withholding of expensive
therapies. The new technologies and procedures can be very expensive to
implement but may be required to lure new patients and medical staff.
Resource allocation and distribution along with rationing health care
reflects a business, rather than patient care, focus.
The Emergency Medical Treatment and Active Labour Act of 1986 (EMTALA) was
enacted to ensure access to health screening for all people who present
regardless of their ability to pay. The number of people seeking and
requiring medical attention without insurance or ability to pay is
increasing, causing a shift in healthcare delivery, due to legal mandate to
provide care for all. On any given night in a busy Emergency Room, the
‘regulars’, drug seekers and pungent homeless can be found, these individuals
still deserve dignity and care, regardless of a nurse’s personal feelings or
beliefs. System abuse and limited resources influence nurses’ perspective on
ethical care. People in a society have a right to healthcare, but policy
makers appear to disregard the ability of resource limited health systems to
provide that care, potentially to the detriment of others. As a result there
has been significant downsizing, and closures of care centres.
Another aspect influencing the aim of nursing ethics is modern globalisation
with changes in patient populations. Immigration in the United States, particularly from Latin-American countries is rising, with the Hispanic
population now being the largest minority group.
Issues affecting professional practice
Professional nursing practice has been dramatically impacted by the recent implementation
of the Health Insurance Portability and Accountability Act, or "HIPPA", which
went into effect April 14 2003. The Act makes legally accountable the ethical
obligation to respect patient health information and privacy. Healthcare
providers must now take active measures to protect against unauthorized uses
and disclosures of personal medical information or be held in breach of
confidentiality or criminally liable.
Olson (2003) suggests that nurses have a professional duty and responsibility
to maintain confidentiality of patient information and to protect patients’
right to privacy. Protection of these rights is crucial with advancement in
nursing informatics, computerized documentation, and medical record storage.
However the new privacy law does have a downside: by inhibiting access to
information, it can be very frustrating for relatives seeking information
about a loved one’s health status. As a recent personal example, a woman’s
mother was recently hospitalised and mechanically ventilated rendering her
unable to give permission to divulge information. Other parties were then
unable to find out the seriousness, and prognosis of her condition. Also the
inability to provide information can inhibit or delay patient treatment, as
health insurance providers often decide authorization for treatment. Nurses
previously could supply information including, condition, injuries and vital
There is undeniable evidence that the issue of nurse-to-patient ratio is a
critical issue in current professional practice. A recent study identified
staffing patterns that limit patient access to nursing care as the issue
"most personally disturbing" to nurses (Fry & Riley, 2002). Studies
further show that a lower ratio of licensed nurses to patients increases positive
outcomes by decreasing infection rates, complications, re-admissions, and
death (Philbrook, 2003). In September 2002, California Governor Gray Davis
passed legislation to establish a nurse-to-patient ratio to address the
quality of patient care and help meet current workforce needs. By ensuring
adequate staffing levels and appropriate workloads, these regulations improve
not only patient care but also nursing working conditions and satisfaction.
As a result of cost containment and scarce resource allocation, nurses are
presented with ethical challenges of justice in the present fiscal
environment in healthcare. Sometimes providing adequate care and maintaining
professional nursing practice is challenging in cost-constrained hospital
environments (Ritter-Teitel, 2002). Nurses are expected to provide quality
patient care based on the same or fewer resources (O’Connor, 1997).
Finally, of end of life care is also a significant issue in professional
practice due to the aging population and the increase in life-extending
technology. The Patient Self-Determination Act of 1990 provides a means for
predetermination of care when the patient is unable to do so. This provides
advance directives about withholding resuscitation and life extending
measures, and by doing so ensures the patients right to autonomy. However,
there can be family or medical refusal to adhere to these wishes and
directives, using the excuse of benefiting the patient.
With unprecedented advances in technology and health science, the profession
of nursing faces a variety of ethical issues. Nursing’s ethic of care and
respect of human rights, along with basic moral principles of autonomy,
beneficence, nonmaleficence, justice and confidentiality provide a framework
for ethical analysis and decision-making. The continued provision of
competent and ethical care, when faced with today’s practice issues,
illustrates the commitment of the nursing profession to nursing ethics.
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