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An Exploration of the Relationship Between Patient

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nursing practice

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DOI: 10.1191/0969733002ne537oa · Source: PubMed

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An Exploration of the Relationship Between Patient Autonomy and Patient

Advocacy: implications for nursing practice
Deirdre Hyland
Nurs Ethics 2002; 9; 472
DOI: 10.1191/0969733002ne537oa

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http://nej.sagepub.com/cgi/content/abstract/9/5/472

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 AN EXPLORATION OF THE
RELATIONSHIP BETWEEN PATIENT
AUTONOMY AND PATIENT ADVOCACY:
IMPLICATIONS FOR NURSING PRACTICE

Deirdre Hyland

Key words: advocacy; nursing practice; patient autonomy; role of the nurse

The purpose of this article is to examine whether patient/client autonomy is always com-
patible with the nurse’s role of advocacy. The author looks separately at the concepts of
autonomy and advocacy, and considers them in relation to the reality of clinical practice
from professional, ethical and legal perspectives.
Considerable ambiguity is found regarding the legitimacy of claims of a unique
function for nurses to act as patient advocates. To act as an advocate may put nurses at
personal and professional risk. It may also be deemed arrogant and insulting to other
health care professionals. Patient autonomy can be seen as a subcategory of the right of
every individual to self-determination, and as such is protected by law. However, it is
questionable whether the traditionally paternalistic approach to health care provision
truly respects the autonomous rights of each patient.
The author considers examples and cases from the literature that resulted in profes-
sional and/or personal difficulties for the nurses involved, and also reflects on an incident
from her own practice where a positive outcome was achieved that demonstrated com-
patibility between the concepts under consideration.

Introduction
The concepts of patient/client autonomy and patient advocacy have featured
prominently in the nursing literature during the past two decades, but there is
still no clear consensus as to the meaning of either concept, and on whether they
have been incorporated into nursing practice. The compatibility of patient/client
autonomy with nurses’ proclaimed role as patient advocates is questionable. Can
one fully acknowledge the patient’s right to self-determination while also claiming
the role of advocate? Do nurses, in fact, have any right to assume a unique
position as a patient advocate among a multitude of health care professionals? In

Address for correspondence: Deirdre Hyland, 48 Burrowfield Road, Sutton, Dublin 13, Republic
of Ireland. E-mail: dhyland@stjames.ie

Nursing Ethics 2002 9 (5) © 2002 Arnold

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 The relationship between patient autonomy and patient advocacy 473
order to explore these questions it is necessary to examine the notions of
autonomy and advocacy from professional, ethical and legal perspectives, creating
a link to the reality of clinical practice.
I am presently employed as a clinical nurse manager in a 31-bedded surgical
unit, which is a tertiary referral centre for patients with cancers of the head and
neck, and with gynaecological cancers. The diagnosis of cancer is always devas-
tating, but when disease and potential treatment lead to marked changes in
appearance and function, it is particularly difficult.1 The area of information
giving, whether in relation to diagnosis and treatment options or to poor prog-
nosis, raises ethical dilemmas that greatly challenge health care providers and will
be one of the issues I will address in this article. In order to consider the com-
patibility of patient advocacy with patient autonomy, it is first necessary to
attempt to clarify both concepts.

Advocacy
The term ‘advocate’ has its roots in the legal profession. It is derived from the
Latin advocatus, meaning ‘one summoned’ or ‘called in’ to plead the cause of
another before a tribunal or court.2 The idea of an advocate as the defender or
promoter of patients’ rights is a common theme in nursing literature. 3 According
to Bird4 ‘it involves pleading the cause of one’s client: the intercession for, or the
defence of, someone. It means defending someone even if they are wrong, and
are known to be wrong’.
Such a strict interpretation of advocacy has frightening implications for nurses,
should it be incorporated into their professional role. However, interpretation
seems to have been amended to suit the needs of the profession. According to
Melia, 5 support for patient advocacy developed from obvious efforts to carve out
an area on which nursing ethics could focus. Like other nursing theories, such as
models of nursing and primary nursing, the idea that nurses have a unique
function as advocates for patients was first mooted in the USA.6 Nurse theorists
appear to have seized on the notion of advocacy to add weight to the argument
for professionalization. However, Willard 3 believes that the advocacy debate
detracts rather than contributes to meaningful discussion concerning the value of
nursing and its importance in patient care.
Examining various definitions of advocacy in the nursing literature, Webb7 con-
cluded that the nurse advocate was expected to ensure that:
• Patients had enough information to exercise autonomy;
• Their legal and moral rights were respected;
• Health care resources allowed appropriate quality and quantity of care.
According to Leddy and Pepper,8 nurses express the advocacy role by creating
an atmosphere that is open and supportive of the individual patient’s decision
concerning care. These definitions certainly appear to be compatible with the
notion of patient autonomy, but do little to recognize the professional knowledge
and judgement of nurses, which may not be in accordance with the patient’s
wishes. Should a nurse caring for a diabetic patient advocate for his or her right
to eat whatever he or she wants, regardless of the consequences, or should the

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474 D Hyland
nurse endeavour to ensure that the patient complies with dietary restrictions? In
such a situation there is obvious conflict between the nurse’s duty of care and the
advocacy role, particularly if one accepts that the nurse should promote the
patient’s right to exercise autonomy, even while disagreeing with the patient’s
choice.
The obligation of nurses to be patient advocates is enshrined in the American
Nurses Association code of ethics,9 and in British10 and Australian codes of pro-
fessional practice. 9 The Irish code of professional conduct11 does not attempt to
impose a formal role of patient advocate on the nurse, but states that: ‘Any cir-
cumstances which could place patients/clients in jeopardy or which mitigate
against safe standards of practice should be made known to appropriate author-
ities’. That said, the recent Irish scope of practice document12 states that ‘the ther-
apeutic relationship between the nurse and the patient/client . . . serves to
empower the patient/client to make life choices’, and that, ‘Nursing practice
involves advocacy for the individual patient/client and for his/her family. It also
involves advocacy on behalf of nursing within the organizational and manage-
ment structures within which it is delivered’ (p. 29).12
One of the main arguments in support of the ‘nurse as advocate’ debate is the
premise that nurses are afforded intimate and prolonged access to patients
compared with other health professions and thus have some idea of what life is
like for patients. 5,9 Melia 5 qualifies this by admitting that such a vantage point
should not be overstated: ‘only the patient knows the patient’s view’. The sug-
gestion is made that ‘the nurse is best placed to act as advocate due to her twenty-
four hour presence in the clinical area’.13 However, this implication of a collective
consciousness is unrealistic. In today’s clinical setting, nurses’ autonomy and dis-
cretion in establishing reciprocal relationships with patients are constrained by
workload and discontinuity of care.14 Although an individual nurse may form a
particular bond with a patient, and gain intimate insight into his or her psyche,
it cannot be assumed that such links recur within each nurse–patient relationship.
Most nurses work shifts of varying length. Difficulties in recruitment and reten-
tion of nursing staff have led to increasing flexibility of staff rostering to accom-
modate individual needs. In the clinical area one of the greatest difficulties facing
nurse managers is to ensure effective communication in order to maximize con-
tinuity of care. Although this does not mean that nurses may not act as patient
advocates, it does suggest that they are not uniquely placed for the role.
Alternative models of advocacy include specially appointed independent
counsellors, voluntary groups, hospital administrators, chaplains, social workers
and family members.6,7,15
Claims that advocacy is a ‘unique function’ of the nurse could be seen as insult-
ing to other health care professions, who are also bound by professional codes of
conduct. Melia 5 contends that the assumption of an advocacy role for nurses
implies that doctors do not care and thus place patients in need of an advocate.
It also suggests that other health care professionals, and indeed, the system, are
working against the patient’s best interest. Can nurses be sufficiently removed
from the organization and from the ideologies of nursing, as well as from those
of health care in general, to make and plead a patient’s case as an advocate would
have to do?5
Bird4 considers that to claim that patients need advocates suggests that the

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 The relationship between patient autonomy and patient advocacy 475
whole fabric of decision making is unsound. She advises that ‘if the multidisci-
plinary team exercise their responsibility and accountability in acting in the best
interests of the patient in carrying out their duty of care and to avoid harm – then
advocacy is not necessary’. Similarly, Mallik 6 states that, as all health care pro-
fessionals are expected to give quality care to their clients, no single group should
need to act as watchdog for another.
In my clinical area, the needs of patients are met by a wide variety of multi-
disciplinary team members, including doctors, nurses, clinical nutritionists, social
workers, speech therapists, and physiotherapists. Through their interaction with
patients, any team member may gain knowledge that may influence the course
of patient care. The multidisciplinary team meets weekly to discuss patient-related
issues, and all contributions are equally valued. An interesting development has
been the inclusion of specialist nurses and cancer co-ordinators within the health
care team. The appointment of specialist nurses, who have their own client case-
load, could indicate a significant shift in the professionalization of the advocacy
role for nurses.6
It has also been contended that the assumption of an advocacy role actually
takes power away from the patients. 4 Bird4 believes that nurses help patients to
assert control over the factors affecting their lives. She considers the nurses’ role
is a complex one of empowerment rather than advocacy. Martin 16 endorses this
but states that, for empowerment to exist, nurses need both a managerial struc-
ture and an educational process that supports and encourages the development
of the essential attributes necessary to facilitate the empowerment of patients.
There is still significant evidence that nurses are themselves an oppressed group
and lack autonomy. In order to empower others, nurses must first learn to
confront sources of oppression and become empowered themselves.17
The legal situation regarding patient advocacy is vague at best. Although the
literature supports the ‘advocacy rhetoric’, its achievement in practice can demand
that nurses take considerable personal and professional risk.18,19 Mallik 6 advises
that, if patient advocacy involves heroic action, nurses may not always be able to
fulfil the role.
In Ireland, a ward of court case20 demonstrated a divergence between medical
law and medical ethics, and led Cusack21 to conclude that what is lawful and
what is ethical in accordance with medical and nursing guidelines are not auto-
matically synonymous.
The ward of court case concerned a woman who had been in a near persistent
vegetative state (PVS) for over 20 years after a catastrophic medical accident.21
The guardian appointed by the courts (in this case the ward’s mother) made appli-
cation to the courts for the removal of the gastrostomy tube that was providing
the patient’s only source of hydration and nutrition. Medical and nursing staff
caring for the patient were vehemently opposed to the withdrawal of the tube.22
However, applying a modified ‘best interests’23 test, the Supreme Court declared
that the withdrawal of medical treatment in a patient with near PVS was lawful.
This was based on the finding that, under article 40 of the Constitution, the ward’s
right to bodily integrity and privacy (including self-determination), and the right
to refuse medical treatment, must be respected.
Responding to the decision of the Supreme Court, An Bord Altranais24
stated that, in this specific case, ‘a nurse may not participate in the withdrawal

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476 D Hyland

or termination of the means of nutrition and hydration by tube. In the event of

withdrawal . . . the nurse’s role will be to provide all nursing care’. Thus the case
caused not only ethical and legal, but also professional dilemmas.
Conversely, in the UK the Lovell case25 represents a situation in which nursing
and medical staff acceded to the wishes of a patient who repeatedly disconnected
his ventilation tubing and asked to be allowed to die. The patient had required
ventilation for the previous eight years, with no hope of regaining independence.
After lengthy consideration, the health care team turned off the alarm on the ven-
tilator, so that the next time the patient disconnected the tubing no action was
taken. An inquest ruled that the staff had acted correctly on behalf of the patient:
‘Mr Lovell made a rational choice and was allowed the dignity of deciding his
own fate.’ However, this case generated considerable controversy, causing great
distress to the nursing and medical teams involved.
It is apparent from the literature reviewed that the issue of patient advocacy is
a complex one and may not be described as a unique function of nurses. However,
it is seen as part of the professional role of nurses, which may best be opera-
tionalized within the context of a supportive organization and good interdisci-
plinary relationships.
Descriptions of advocacy in the literature contain many features similar to
beneficence, leading to a possible assumption that beneficence and advocacy are
one and the same thing.3 All health care professionals, not just nurses, owe a duty
of beneficence to their clients, but Willard 3 points out that the major difference
between these concepts arises from the advocate’s concerns about promoting the
autonomous decisions of the patient. While acknowledging that there are very
compelling reasons for supporting patient autonomy, she states that: ‘The possible
consequences of respecting autonomy are sufficiently serious to prevent it from
becoming an absolute obligation’ (p. 63).3

Autonomy
Autonomy is one of the moral principles commonly mentioned in bioethical dis-
cussions, the others being nonmaleficence, beneficence, and justice.15
Etymologically, the term ‘autonomy’ is derived from the Greek autos, meaning
self, and nomos, meaning rule, governance or law. To be autonomous means to be
in control of one’s life. McParland et al.26 define self-determination as ‘the ability
to understand one’s own situation, to deliberate, to make plans and choices, and
to pursue personal goals’. The code of professional conduct for Irish nurses11
directs that ‘it is necessary for patients to have appropriate information for making
an informed judgement. Every effort should be made to ensure that patients
understand the nature and purpose of their care and treatment.’
According to Tomkin and Hanafin, 27 the idea of consent appears to express the
law’s respect for the autonomy of the individual. The law requires that a doctor
can treat a patient only if he or she has consented to treatment, unless the patient,
by age or incapacity, is unable to give consent, or in exceptional emergency situ-
ations. In Ireland, a doctor must disclose to a patient (or the patient’s parent or
guardian) information about the patient’s condition, the effects of treatment
(including side-effects) and also, where appropriate, alternative forms of treat-

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 The relationship between patient autonomy and patient advocacy 477

ment.27 If a doctor, or other health care professional, undertakes a treatment to

which a patient has not consented, he or she could be guilty of battery.28 The tort
of battery represents the importance of an individual’s right to determine what
should, or should not, be done to his or her body.
In common with a number of other countries, such as the UK and Australia,
relevant Irish case law is founded mainly on the ‘reasonable doctor’ principle,
rather than the ‘informed consent’ principle endorsed by most states in the USA.29
This means that doctors can be accused of withholding information only if they
did not reveal what most or many reasonable and competent doctors in a given
particular branch of medicine would disclose in similar circumstances.15 Healy 30
believes that this model is weighted in favour of the medical profession, whereas
the ‘informed consent’ law is more likely to address fully the legal issues arising
from disclosure, and would therefore encourage doctors and other health care
professionals to improve their relationships with patients.
The Irish Medical Council31 emphasizes that, when patients request additional
information, they should be given a positive answer. However, this has not been
tested in court, and there is a lot of latitude for doctors to interpret how much
information patients need. Healy 32 asserts that not to recognize a distinction
between an inquisitive and a reticent patient is tantamount to a complete rejec-
tion of the patient’s right to self-determination. He goes on to say:
One patient might coyly murmur ‘It isn’t dangerous, is it, doctor?’ Another patient
might timidly defer to whatever the doctor says. Yet both, if put to the test, might
equally want the same level of truthfulness and disclosure from the doctor.
At such times nurses, as patient advocates, are ideally placed to mediate and
to assist patients and families to clarify their concerns.9
Traditionally, patients deferred unquestioningly to the opinion of the doctor:
the ‘doctor knows best’ syndrome. The adoption of the ‘sick role’ is thought to
be one of the major factors in reducing autonomy and stimulating a paternalis-
tic response in health care professionals.33 Biley 34 describes how individuals,
when given the label of ‘patient’, were expected to assume a passive, dependent
role, but believes that in recent years this role has changed from one of passivity
to activity. This may have less to do with enlightenment on the part of the medical
and nursing professions than with increased public expectation.
Factors influencing increased recognition of the right to patient autonomy are
statutory and professional regulations, increased public knowledge and access to
relevant information, and fear of litigation. 15,29 Factors limiting patient autonomy
include traditional attitudes, fear, lack of knowledge, an unfamiliar environment,
and intimidating health care professionals.3,26
Johnstone15 raises doubts about whether there has been a major shift in the
level of autonomy achieved by patients, and believes that, if autonomy is to be
taken seriously by nurses, they must respect patients as dignified human beings
capable of deciding what is in their own best interest, even if what they (the
patients) decide seems foolish to others. This could prove problematic. McParland
et al.26 point out that respect for autonomy cannot be an absolute obligation
because it may conflict with the professional responsibility to act beneficently
towards patients, and could thereby compromise the moral autonomy of health
professionals.

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478 D Hyland

In a similar vein, Woodward35 warns that overemphasis on patient autonomy

may confuse and suppress beneficent interventions, and reminds us that if harm
is caused to patients by either act or omission then professional duty has not been
fulfilled: ‘Promoting patient autonomy for its own sake does not necessarily con-
stitute moral agency.’35 Giving supremacy to autonomy over other ethical princi-
ples (such as beneficence or respect for the integrity of the individual) could
actually be seen as an abandonment of patients in times of need.36
If a patient for whom a nurse is caring makes an autonomous decision that will
result in some harm, a conflict arises between the client’s right to autonomy and
the nurse’s professional duty of care. The problem may be resolved, perhaps
unconsciously, through the use of weak paternalism. 33 Thus, a nurse may be
aware that a frail, bed-bound patient is at high risk of developing decubitous
ulcers, and requires regular changing of position to relieve the pressure areas. If
the patient protests at being disturbed, should the nurse assent to the patient’s
wishes, or should the nurse use persuasion and negotiation to win co-operation?
If the nurse uses coercion, there is a risk of an accusation of resorting to strong
paternalistic behaviour.
In defence of paternalism, it has been argued that not all patients want to
exercise autonomy. At times, they have no need to express autonomy and wish
to adopt a more dependent role.35 Having sought expert advice, a patient may
have decided to accept the view of someone else. 18 Forcing the patient to accept
an autonomous role could in itself be seen as a form of paternalism.

Putting advocacy and patient autonomy into practice

Few studies have examined the practical utilization of the notions of advocacy
and patient autonomy in the clinical area. However, Mallik 37 produced useful data
when she examined the perception of practising nurses of their advocacy role.
Among the situations that prompted nurses to advocate were patients’ fear of
medical authority, patients’ vulnerability, and direct patient requests. Patients
often appeared genuinely afraid to ask questions or voice a need to a doctor, par-
ticularly during the ward round. Statements revealed that they were unable to
argue their points of view. They became ‘frozen’ and could not take part in ward
round discussions. Although wishes may have been expressed to a nurse before-
hand, these had to be represented to the consultant by the nurse. Such scenarios
are familiar to any experienced clinical nurse, although he or she may not be con-
sciously engaging in advocacy.
Another example from Mallik’s study37 had particular resonance for me. Mallik
describes how incidents of making a judgement that someone was dying, and
fighting for that person to remain where they were to die peacefully and with
those they knew, was evident in some examples of advocacy. This vividly brought
to my mind an incident in which nurses intervened to ensure that a patient’s
autonomy was respected.
Tim (pseudonym) was an 85-year-old man who was diagnosed with advanced
cancer of the larynx. The treatment option was radical surgery, followed by radio-
therapy, with a poor prognosis for survival. Having survived cancer of the
prostate 20 years previously, Tim decided that he had enjoyed a good life, and

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 The relationship between patient autonomy and patient advocacy 479

did not wish to have surgery. His only wish was to have a pain-free death, with
his family present. To relieve his airway distress, a tracheostomy was performed,
but Tim refused to have a gastrostomy tube inserted. He was very open in express-
ing gratitude to the staff and his family for any attentions given. When offered a
private room, his answer was: ‘Aren’t I fine here, what more could I want?’
When it was evident that Tim’s condition was deteriorating, and that no further
intervention was possible, the medical team proposed to send Tim back to the
regional centre from where he had been referred. Tim’s family became extremely
upset when they heard this, owing to the bond of trust that had been established
between the patient and the staff. In addition, the nursing staff believed that Tim’s
condition was deteriorating rapidly, and that he may indeed die during the
transfer. Nursing staff used the forum of the multidisciplinary meeting to
advocate that the patient be allowed to stay in the ward. This was agreed, and
Tim died peacefully two days later, surrounded by his family.
Although there may be disagreement about whether patient autonomy and
advocacy are always compatible, this example indicates that there are occasions
when they are, and that advocacy need not always be adversarial. One of the
main factors contributing to Tim’s ability to exercise autonomy was the open and
honest approach to information-giving within the unit, which is part of the ethos
of care.

The value of information-giving in promoting

autonomy
When a patient is severely ill, there is a tendency to treat him or her as a person
with no right to an opinion.38 If it is accepted that people have the right to make
informed choices, can they be denied the knowledge and information they require
to do so? During her seminars on death and dying, Kübler-Ross38 found that most
patients believed they were entitled to be fully informed about their condition,
and felt anger at being shielded, either by family or doctors.
Twenty-five years later, many people with cancer still seem manifestly unhappy
with the amount of information they receive. 39 In a study of 101 patients with
cancer, Fallowfield et al.39 found that, although doctors may genuinely believe that
they are protecting their patients, fear and anxiety are actually increased by a lack
of openness. They acknowledge, however, that some people may not want to
know their diagnosis, and that this should be respected also. Thompson et al.40
illustrate this dichotomy by noting that ‘to be kept in a state of ignorance is to
be kept in a state of dependence, to be infantilised and controlled’, but also caution
that the callous imparting of a fatal diagnosis could constitute a form of abuse.
Confronting a patient with a devastating diagnosis requires experience and skill.
Describing the giving of bad news as ‘an art’, Kübler-Ross38 wrote that ‘if a doctor
can speak freely to his patient about the diagnosis of malignancy, without
equating it necessarily with impending death, he will do the patient a great
service’.
Nurses are well placed to become aware of whether patients have unmet infor-
mation needs.41 It often falls to nurses to explain information obtained from other
health care professionals that was only partly understood by patients. 26 Patients

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480 D Hyland

may ask nurses questions that they are afraid to put to the doctor. This may
produce an ethical dilemma for nurses, because they must decide whether to
divulge information that may have been withheld, either unconsciously or delib-
erately, or about which they may not have the necessary knowledge to explain.
This represents another situation where nurses could assume an advocacy
role and make representation to the medical team on behalf of patients.
Johnstone15 warns that nurses should be aware that, by giving additional infor-
mation to patients, they may be taking a risk because this could be construed as
interfering with the physician–patient relationship. It may also place their career
in jeopardy, as was illustrated by the ‘Nurse Tuma’ case in the USA.14,41 Nurse
Jolene Lucille Tuma was asked by a patient, who was due to undergo chemother-
apy, to provide information about alternative methods of treatment, which Tuma
agreed to do. Having considered the information, and discussed the options with
her family, the patient continued her chemotherapy regimen, but died two weeks
later. The physician, who was informed of Nurse Tuma’s involvement by the
patient’s family, reported her actions to the State Board of Registration. Nurse
Tuma was removed from the nursing register, on the grounds that she had inter-
fered with the physician–patient relationship.
When providing information, it is apparent that nurses need to have established
adequate communication with other members of the health care team, but they
also need to be aware of their professional and legal obligations. The guidelines
found in the Irish code of professional conduct11 state that: ‘In certain circum-
stances there may be a doubt whether certain information should be given to a
patient and special care should be taken in such cases.’ This statement seems
highly ambiguous and open to a variety of interpretations. The legal situation,
while doing little to recognize the nurse as an independent practitioner, at least
seems to be clear: ‘When a patient seeks an explanation or clarification [regard-
ing a contemplated procedure] the nurse is obliged to refer the matter back to the
doctor.’42

Conclusion
The question posed in this article was: is patient/client autonomy always com-
patible with the nurse’s role of advocacy? The simple answer must be no, not
always. Although I contend that nurses cannot claim a unique role as patient
advocates, nevertheless there may be occasions when nurses realize a need to
advocate on behalf of their patients. Although required by law and professional
guidelines to promote the autonomy of their patients, nurses may be constrained
by risk to self or to patients, or by lack of support from the organization or fellow
health care professionals. In order to be effective advocates, nurses need to be rec-
ognized, and to recognize themselves, as equal partners within the multidiscipli-
nary team. They also need to be confident of the support of their employer and
professional organizations.
The right of patients to autonomy is seen as a subcategory to human rights.
The right to self-determination is recognized by law, and should be respected by
all health care professionals. However, if nurses’ support for patients’ autonomy
leads to harm, either to the patient or to others, nurses may stand accused of

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 The relationship between patient autonomy and patient advocacy 481

negligence, by act or omission. Promoting patients’ right to autonomy, regardless

of the consequences, may also create tension between these rights and nurses’
duty of care.
Nursing care is not an exact science and it is not possible to provide one answer
to the infinite number of dilemmas that will confront nurses during their nursing
career. An awareness of ethical, legal and professional obligations will at least
help nurses to consider all aspects of a particular situation, in order to decide the
best course of action. Armed with this knowledge they can confidently take their
place within the health care team, advocating in support of patients’ right to
autonomy, if, and when, the need arises.

Acknowledgements
I wish to acknowledge the helpful advice of Ms Catherine O’Neill and Mr Gordan
Duffy while preparing the final draft of this article.

Deirdre Hyland, St James’s Hospital, Dublin, Republic of Ireland.

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