The intent of this position statement is to offer guidance to registered professional nurses facing ethical issues in practice and to share a framework for ethical decision-making that can be utilized to recognize and resolve ethical dilemmas.
The New York State Nurses Association believes the registered professional nurse should respond to ethical dilemmas by:
The climate of advancing medical technology coupled with economic and human resource limitations contributes to the need for discussion about the evolving roles and responsibilities of registered professional nurses on ethics committees, as participants in ethics rounds and interdisciplinary ethical decision-making processes.
In the 1970’s, ethics committees began to be established in response to the Quinlan case in New Jersey (Fletcher & Hoffmann, 1994). These committees were convened to address patient care issues in practice. In 1990, the Center for Ethics and Human Rights became a part of the American Nurses Association structure in response to a House of Delegates recommendation that ethics and human rights issues be integrated throughout ANA. In 1991, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandated that institutions address ethical issues related to patient care and required that health professionals be educated about ethics (JCAHO, 2004).
In a 2004 National Ethics Teleconference, JCAHO emphasized that healthcare institutions need to “respect the culture and rights of patients” by “respecting patient autonomy and shared decision-making” (JCAHO, 2004, p3). JCAHO recommends that ethics committees be involved in issues such as:
Registered professional nurses are in the best position to advocate for the rights of their patients and are frequently involved in ethical issues and ethical decision-making processes. Ethical dilemmas arise daily when the nurse is confronted with a choice, in which ethical reasons both for and against the choice are equally desirable (Pierce, 1997). These issues are often emotionally charged. Recent literature (Donovan & Redman, n.d.; Cassells & Gaul, 1998; Clark, 2002; Dinc, 2003) has identified some of the more frequently occurring ethical issues confronting nurses today, including:
A vital component in nursing education, in both undergraduate and continuing education, is the need to:
The registered professional nurse, in facilitating the ethical decision-making process, can utilize different frameworks and models. First and foremost, the ANA Code of Ethics with Interpretative Statements offers a statement of every professional nurse’s ethical obligations and duties, ethical standard, and commitment to society (ANA, 2001). The first provision states, “The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems” (ANA, 2001, p. 18). Provision 5 supports the need to identify both personal and professional values, “The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.” The provision speaks to the nurse’s obligation to respect oneself and to “embrace the values of the profession, integrating them with personal values (ANA, 2001, p. 19).
A framework nurses may choose to use for ethical decision-making developed by Cassells (Cassells & Gaul, 1998) provides a systematic approach to processing an ethical issue in nursing practice:
Plan of Action
*©Framework: ASEAS Instrument:Cassells, J. & Silva, M. 1990
Revised: EAF/Nursing process:Cassells, J. Johnson, E & Littlejohn, J. 1996
Revised: EAFCassells, J. & Gaul, A.L 1997
© 1998: Ethical Assessment Framework (EAF)
Judith M. Casseus, RN, DNSC (et. al)
Reprinted from Maryland Nurse, 1998, p.9. Reprinted with permission of the author, Cassells, J.
The New York State Nurses Association recommends that registered professional nurses:
Reviewed and revised by the Councils on Ethical Practice and Human Rights on April 29, 2005.
Approved by the Board of Directors on June 8, 2005.
Note: The use of the term “patient” anywhere in this document is intended to be generic and refers to the recipient of nursing care.
Note: This position statement combines three previously developed position statements, Position Statement on Ethics Committees and the Role of the Professional Nurse (1988, Revised 1992 and 1999), Position Statement on Ethical Decision-making (1997) and Position Statement on Ethics Rounds (1982, Revised 1992)
Autonomy: The right to self-determination. An ethical principle that involves the nurse’s willingness to respect patients’ rights to make decisions about and for themselves, even if the nurse does not agree with the patients’ decisions.
Beneficence: The duty to do good; prevent harm and remove harm.
Care: A broad concept that “in its simplest form, can be described as an attitude or orientation that leads to the beneficent attending, through acts or omissions, of one person towards another” (Cortis & Dendrick, 2003, p.78).
Ethics: The study of values in human conduct or the study of right conduct. Ethics offers a critical, rational, defensible, systematic and intellectual approach to determining what is right or best in a difficult situation.
Justice: The equitable distribution of risks and benefits. Equals ought to be treated equally and unequals may be treated unequally.
Moral: The personal beliefs and cultural values that are the basis for human conduct.
Nonmaleficence: The obligation not to inflict harm intentionally (Beauchamp & Childress, 2001).
Values: The set of personal beliefs and attitudes that we hold in high regard.
Advance Directive: Written instruction recognized under state law relating to the provision of healthcare when an individual is incapacitated. Advance Directives may take two forms:
Nurses, regardless of their practice setting, face inherent ethical situations. These situations may require consultation with an ethics committee and/or presentation in nursing or medical ethics rounds.
Intravenous hydration and a feeding tube are ordered for a terminally ill patient with Alzheimer’s dementia who is no longer able to make his own decisions. The healthcare proxy states, “no artificial nutrition and hydration,” yet the healthcare agent insists that a feeding tube be inserted.
An order for a feeding tube is written for a semi-comatose patient who has no healthcare proxy or advance directives. A distant relative who has had no recent contact with the patient objects to the feeding tube. New York State law does not recognize surrogate decision-making where family members or others close to the patient may make healthcare decisions when the patient cannot. In this situation, where the patient is incapacitated and without a health care proxy or an advance directive regarding hydration and nutrition, an ethics consult is warranted.
Opioid medication is being provided around the clock for an advanced lung cancer patient with several weeks of refractory pain. The patient's level of sedation has recently changed and the patient now appears to be in a light to deep sleep most of the time. The family members have asked the Hospice RN to request that the doctor reduce the dosage of the pain medication because they fear this level of sedation could hasten death. The patient's advance directive states that pain medication should be administered to alleviate suffering.
American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Washington, DC: Author.
American Nurses Association. (2004) Nursing: scope and standards of practice. Washington, DC: Author.
Beauchamp, T. L. & Childress, J. F. (2001). Principles of biomedical ethics (5th Ed). New York: Oxford University Press.
Berkowitz, K. & Chanko, B. (2004, April 27). National ethics teleconference: ethical principles at the foundation of JCAHO’s ethics, rights and responsibilities standards. (Available from the Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL)
Blake, C.B. & Guare, R.E. (1997). Nurses’ reflections on ethical decision-making: implications for leaders. The Journal of the New York State Nurses Association. 28(4): 13-16.
Cassells, J.M. & Gaul, A.L. (1998). An ethical assessment framework for nursing practice. Maryland Nurse, 17(1): 9-12.
Clark, C. (2002). Ethical decisionmaking in the business of healthcare. Retrieved March 18, 2005, from http://itc.boisestate.edu/mediashowcase/media/EDM_Spring_2002.pdf
Cortis, J.D. & Kendrick, K. (2003). Nursing ethics, caring and culture. Nursing Ethics, 10, 77-88.
Dinc, L. (2003). Ethical issues regarding human cloning: a nursing perspective. Nursing Ethics,10, 238-254.
Donovan, C. & Redman, B. (n.d.) Ethics and human rights issues in nursing practice: a survey of Connecticut registered nurses. Retrieved February 18, 2005, from http://jmrileyrn.tripod.com/ene/research.html
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Fletcher, J.C. & Hoffmann, D.E. (1994) Ethics committees: time to experiment with standards. Annals of Internal Medicine, 120, 335-338.
International Council of Nurses. (2000). International code of ethics. Geneva, Switzerland: Author.
Joint Commission for Accreditation of Healthcare Organizations. (2004). Comprehensive accreditation manual for hospitals. Oakbrook terrace, IL: Author.
Matzo,M.L., Sherman, D.W., Nelson-Marten, P., Rhome, A. & Grant, M. (2004). Ethical and legal issues in end-of-life care: content of the end-of-life nursing education consortium curriculum and teaching strategies. Journal for Nurses in Staff Development, 20(2), 59-66
McDaniel, C. (1998). Hospital ethics committees and nurses’ participation. Journal of Nursing Administration, 28 (9), 47-51.
Pierce, (1997).What is an ethical decision. Critical Care Nursing Clinics of North America, vol.9, 1 March, 1-11. #12 back.)
Phillips, B. (2003 ) Survival on the ethics committee: a nurse’s guide. Community Ethics, 4(1). Retrieved February 22, 2005 from www.pitt.edu/~cep/41.6.html
Powell, C. & Nicoll, L. (n.d.). Ethics and human rights issues in nursing practice: a survey of Maine registered nurses. Retrieved February 18, 2005, from http://jmrileyrn.tripod.com/ene/research.html
Re Quinlan, 70 N.J. 10, 355 A. 2d 647, 429 U.S. 922 (1976)
Smith, KV (1996). Ethical decision making in nursing: implications for continuing education. Journal of Continuing Education in Nursing, 27 (1), 42-4.
University of Buffalo Center for Clinical Ethics and Humanities in Health Care. (2000). Bioethics Law in New York State. Retrieved February 22, 2005, from http://wings.buffalo.edu/faculty/research/bioethics/legal.html
When judgments differ. (2004, July-August). Minnesota Nurses Accent, 76(4): 7
For more information on nursing practice, contact NYSNA's Education, Practice and Research Program at 518.782.9400, ext. 282 or by e-mail.