art & science ethical decision-making: 1

An introduction to ethics in nursing

Chaloner C (2007) An introduction to ethics in nursing. Nursing Standard. 21, 32, 42-46. Date of acceptance: February 1 2007.

Summary
Ethics is concerned with 'right and wrong', although agreeing what is 'right' can be challenging. An understanding of ethics is essential to the delivery of skilled professional care. I t is vital that nurses appreciate the value of ethics in their work. Ethics is relevant to clinical, practice-based issues and affects all areas of the professional nursing role. To apply ethics effectively, nurses must develop reasoning skills and understand the concepts and principles that assist ethical analysis. This article, the first in a series of articles relating to ethics and nursing, offers an introduction to ethics, primarily focusing on their application in clinical nursing practice. Throughout the article, the terms 'ethical' and 'moral' are used interchangeably.

'She was right to stop and help at the scene of the accident.' 'It was so good of you to bake me a cake.' 'I am so sorry, I was wrong.' 'You shouldn't do that.' Similarly, an ethical question is usually identifiable by the inclusion of an evaluative term. For example: 'Should treatment be withdrawn?' 'Would it be wrong to lie?' The application of ethics demands the critical examination of such statements and questions. In the example: 'It is wrong to deceive a friend deliberately', the following questions require consideration: Who is making this assertion and in what context? Is the statement supported by objective evidence or is it simply a matter of personal opinion? Are any individual values and beliefs influencing the speaker? Our own ethical claims demand a similar degree of critical reflection. The process can be demanding but without it the temptation is to resort to basic, ill-conceived assertions, such as: 'I think that's terrible', which lack foundation, or to retain an instinctive, and not always reasonable, view of right and wrong based solely on social, cultural and/or religious circumstances. A disconcerting feature of ethics can be its association with apparently complex theories such as utilitarianism (the moral value of an action is determined by its overall benefit) and deontology (concerned with adhering to moral rules or moral duty rather than with the consequences of actions) (Beauchamp and Childress 2001). These established theories are important components of ethics and can help to guide decisions. However, more useful to ethical decision-making in the first instance is a considered appraisal of the fundamental ethical concepts that form the basis of many elaborate ethical theories and principles (Box 1). When faced with an ethical dilemma, that is, when a difficult choice has to be made between two or more alternatives, especially equally
NURSING STANDARD

Author
Chris Chaloner is ethics adviser. Royal College of Nursing, London. Email; chris.chaloner(a)rcn.org.uk

Keyvyords
Codes of conduct; Ethical decision-making; Ethics; Nursing: philosophy These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For author and research article guidelines visit the Nursing Standard home page at www.nursing-standard.co.ui<. For related articles visit our online archive and search using the keywords.

ETHICS IS A BRANCH of philosophy concerned with determining right and wrong in relation to people's decisions and actions. This simple definition serves to demonstrate the inherent difficulty in applying ethics to the realities of daily life. How do we distinguish a right action from a wrong one and who determines what is right and wrong? Ethics is evident when values such as right and wrong (or good and bad) are introduced. The word 'should' is also an indicator of ethical thinking, as it provides a view on the right way to act, for example, in the statement: 'You should tell the truth'. It may also indicate a desire for ethical guidance, for example: 'What should I do?' It is, therefore, possible to recognise ethical statements by their 'morally evaluative' component. Eor example: 'It is wrong to deceive a friend deliberately.'
42 aprii 18 :; vol 21 no 32 :: 2007

undesirable ones, it is essential that those wishing to make an ethically appropriate choice engage in a process of ethical analysis. This may require the identification of the ethical aspects of the situation, the related ethical concepts, ethical questions raised and a consideration of the ethically justifiable options. An example of an ethical dilemma is described in Box 2. Ethics and the law Ethics and the law are closely related. Concepts, such as rights and justice, have both ethical and legal significance. The law and ethics are both instruments of regulation, prescribing how people ought to act in response to one another. In a general sense, the law reflects a society's ethical code, such as the accepted legal and ethical prohibition of intentional killing. Problems arise when the law and ethics clash, for example, when something is lawful yet claimed to be 'unethical' - a view promoted by some anti-abortionists - or

Ethical analysis
Case scenario George, aged 70 years, recently underwent abdominal surgery when it was discovered that he had carcinoma of the stomach. I t was not possible to remove the tumour and there was evidence of a secondary cancerous growth in the liver George's family has been informed of his prognosis. They have requested that he should not be told the truth until it is 'absolutely necessary'. The four key steps in ethical analysis are as follows: 1. Recognise an ethical issue: What, if anything, is problematic in the above scenario? Is the problem practical, clinical or does it have features that demand ethical consideration? Is it possible to clearly state why there is an ethical aspect to this scenario? 2. Which ethical concepts are involved? Truth-telling. Rights.

Ethical concepts
Avoiding harm: this is perhaps the most basic and easily understood ethical concept and it underpins good healthcare practice. Moral obligations and duties: identifying moral rules (that imply ethical duties) can help in deciding on the 'right' thing to do. For example, if truth-telling Is considered to be a 'rule' actions can subsequently be determined by adherence to this rule. Assessing the consequences of actions: it could be claimed that the rightness of an action is determined most effectively by calculating its potential outcomes. Autonomy and rights: to be autonomous is to be self-determining, free from the controlling interference of others. Respect for autonomy is a fundamental principle ethically and legally that influences healthcare decisions, such as those concerning informed consent. What do we mean when we talk about rights? Which, if any rights do we possess? Best interests: identifying (and acting) in the best interests of others often provides ethical justification for an action or decision. Values and beliefs: from these we formulate general ethical principles that provide guidance to ethical decisions and actions. Emotions, relationships and context: is our ethical viewpoint affected if the matter concerns ourselves or those close to us? Do specific circumstances influence ethical decisions? * Moi-al character: is there such a thing as a 'good person'? Is he or she more likely to know the right way to act?

Confidentiality. Autonomy. 3. Ethical questions: Does George have a 'right' to be told the truth? Has confidentiality been breached? If so, in what way and why? Is the breach ethically justifiable? What is the most effective way to respect George's autonomy? Do members of George's family have rights in this situation? 4. Available options: Inform the patient of his prognosis. Agree that he should not be informed. Do nothing (rarely a viable option). Investigate a potential solution, possibly seeking a compromise between the competing rights of the patient and his family that also concurs with professional obligations. Ethical analysis may not automatically provide a satisfactory solution. However, recognising what is and what is not an ethical issue, and identifying the ethical concepts and questions involved, may assist decisions and justifications about what 'should' be done.

'illegal' yet ethically justifiable, which is a claim made by pro-euthanasia activists. Everyday ethics _

Exploring ethical issues is a familiar process. Knowingly or not, we participate in ethical decision-making on a daily basis and are frequently
aprii 18 :: vol 21 no 32 :: 2007 43

NURSING STANDARD

art & science ethical decision-making: 1

required to make moral choices. Our opinions often reflect a moral evaluation of right or wrong and, at times, we are uncertain about the 'right' way to behave. Whenever we make a promise, we make what amounts to a 'moral contract'. When we are bothered by our 'conscience', we are usually reacting to our personal sense of right and wrong. We are regularly exposed to ethical pronouncements. Eor example, the following familiar statements show that ethics is everywhere: 'I demand to be treated with respect.' 'You shouldn't behave like that.' 'You've got no right to say that to me.' 'Well, at least there was no harm done.' 'You can't say fairer than that.' 'We were right to go to war.' 'He is a really good person.' Controversial ethical issues are regularly highlighted in the media and often generate more passion than clarification. The House of Lords debate on assisted dying attracted significant media coverage (Wilson 2006, Woodward 2006), although it is arguable whether some of the enthusiastic, but one-sided appeals (Toynbee 2006), served to inform the debate or detracted from balanced ethical deliberation on the complex and sensitive issues.

confidence in applying ethics to their clinical role (Woods 2005). Nevertheless, the evaluative aspects of health care, such as a consideration of what is morally right and wrong, are as important to effective practice as procedures or techniques. Hence, nurses should regard ethics and ethical thinking as an integral part of their professional skills and knowledge. 'Good' nursing practice requires that practical efficacy and ethics are given equal consideration. Eor example, in the case of a patient undergoing surgery, both the surgical procedure (the practical component) and the patient's informed consent to that procedure (the ethical and legal factor) should have equivalent status in the planning and delivery of care. Nurses regularly face complex practice-based ethical decisions. An appreciation of ethics and the ability to engage in ethical analysis are essential when faced with questions such as: Should patients always be told the truth? What if the truth may cause harm or distress ? Is the disclosure of confidential information morally permissible if it will help others ?

Doing good and avoiding (or minimising) harm

Case scenario A 45-year-old woman makes an informed refusal about life-preserving treatment against the advice of her clinical team. The clinicians face a characteristic ethical dilemma: they wish to achieve the 'good' of life-preservation and avoid the (perceived) 'harm' of death. However, they aiso wish to achieve the 'good' of respecting the patient's informed decision and avoid the 'harm' of overriding her autonomy. When a patient disagrees with the healthcare team it may not be possible to reconcile the interests of all concerned. In this example the ethical decision-making process will involve discussion of equally strong but conflicting concepts: The preservation of life. Respect for individual autonomy. Respecting autonomy is regarded as one of the cornerstones of good practice. Therefore, it is likely that respect for autonomy would outweigh any moral claim that clinicians should intervene to preserve the patient's life and oppose her informed choice. Legally, the competent patient is entitled to refuse treatment. This scenario raises some important ethical questions: To what extent should patients be entitied to request or refuse a medical intervention? Should health professionals ever override a patient's autonomous decision?

MPlyJl!g ethics to nursing practice

Identifying good practice demands a well-reasoned assessment of what nurses do conjoined with an appreciation of how and why they do it. Ethics enables the critical evaluation of nursing decisions and actions. Nursing itself is an ethical activity because its primary aims are to do good and, wherever possible, avoid (or at least minimise) harm - although achieving these aims can be problematic (Box 3). Despite an increased focus on ethics in pre and post-registration nursing education, some nurses still perceive ethics as being remote from the dayto-day realities of their role. They may concede its relevance within the Code of Professional Conduct (Nursing and Midwifery Council (NMC) 2004), or when submitting research proposals -where gaining ethical approval can be viewed as a difficult, even obstructive, part of the process (Moore and Savage 2002). However, they fail to recognise its influence on their practice. Alternatively, some nurses lack 4 4 aprii 18 :: vol 21 no 32 :: 2007

NURSING STANDARD

Practice-based issues create a range of ethical questions (Box 4). Day-to-day professional ethics demand that individuals and teams undertake ethical analysis using their personal and professional skills, knowledge and experience to assist and inform, but not necessarily direct, their decision-making. It is important to note that ethics is not solely concerned with dramatic events or 'dilemmas'. Eamiliar, everyday procedures, such as monitoring a patient's temperature, demand

What is the 'right' thing to do?

Case scenario Charles, aged 50 years, had an operation to relieve chronic back pain. Before his surgery and following a discussion with a doctor, he signed a consent form. The surgery was completed successfully but the next day Charles informed a nurse: 'I didn't have a clue what I was signing when that doctor came to see me the other day, I just did what he asked me to do.' This scenario raises a number of ethical questions: How important is a patient's consent to treatment and the manner in which it is obtained? The surgery was successful: does it really matter if the patient did not comprehend fully the nature, likely outcome or possible risks of the procedure to which he had 'consented'? Has any harm occurred? If so, to whom and in what way? If Charles did not understand why he signed the consent form, was his 'consent' to surgery ethically, or legally valid? Why is it important that a patient should understand what he or she is agreeing to when signing a consent form? In signing the form, did Charies make an autonomous decision? In what way was his autonomy undermined by his lack of understanding of the consent process? I t would appear that Charles's consent to treatment was not valid in this instance. In such a situation it is not possible fully to rectify the 'wrong' that has occurred. Following a team discussion it was agreed that the 'right' course of action was to ensure that: a) The fundamental ethical aspects of the incident, in particuiar the lack of informed consent to treatment, were identified and understood by all members of the clinical team. b) Charles fully comprehended what had occurred, although this would be no defence in court if he subsequently wished to claim that his consent was invalid. c) Measures must be put in place to ensure that such a situation did not reoccur

consideration of important ethical concepts, such as communication - does the patient understand what is happening? It also requires consent - even the most common interventions require informed consent. If nurses do not engage actively with the ethical issues that affect them on a daily basis they will fail to deliver the optimum standard of care to patients. If nurses have not involved themselves in the crucial ethical discussions that precede many clinical interventions, there is little point in them protesting when the ethical view of a doctor, or other professionals, takes precedence over theirs.
Broader pj^qfes^ionalethjcal concerns

Ethics is relevant to all areas of nursing practice and every aspect of the professional role, including research activity, education and management. Nurses should, therefore, be involved actively in ethical decision-making at managerial, educational and strategic healthcare levels. Eor example, the rationing of health resources is a persistent and worrying issue for society as a whole (Revill 2006), and a nursing view should be evident in what remains a medically dominated ethical debate. Nurses should be prepared to contribute to all ethical policy decisions that affect their role and patient care. Other examples of ethical questions raised in the planning and delivery of health services include: > How should limited resources be distributed? Should greater resources be allocated to combat serious disorders that affect a comparatively low number of people, or minor disorders that affect a far greater number? Is it fair that access to some medical treatments may depend on where you live? (Lister 2005). The ongoing public and professional debate on such issues frequently lacks an informed nursing perspective. Professional regulatory bodies provide members with broad ethical guidelines and standards. The NMC's (2004) Code of Professional Conduct guides nurses by establishing appropriate professional standards. The International Council of Nurses (ICN) produces a Code of Ethics (ICN 2006) and a number of international organisations have published useful ethical guidelines (American Nurses Association 2001, Canadian Nurses Association 2002, World Medical Association 2005). UK nurses do not have a detailed code of ethics. Although a 'professional ethics rule book'
aprii 18 :: vol 21 no 32 :: 2007 45

NURSING STANDARD

art & science ethical decision-making: 1

might seem attractive, it could prove counter-productive and deter practitioners from critically examining the ethical aspects of their individual role. The specific features of ethical practice cannot be prescribed and the available codes and guidelines can assist ethical thinking and decision-making, but do not provide an 'ethical solution' to specific problems.

analysis and decision-making. Resolving ethical problems and influencing an ethical healthcare agenda is not easy - it can be challenging for all concerned. However, nurses should be prepared to engage with the issues to ensure that their ethical voice is heard and that their professional activities are ethically sound and justifiable NS
USEFUL RESOURCES
Bioethics Today: www.bioethics-today.org.uk Nuffield Council on Bioethics: www.nuffieldbioethics.org The Ethox Centre: www.ethox.org.uk UK Clinical Ethics Netv\/ork: www.ethics-network.org.uk/index.htm (Last accessed: March 23 2007)

Conclusion
Ethics is not solely a theoretical issue for nurses. It is fundamental to their practical skills and knowledge base. The aim of this series of articles is to help nurses understand how ethics affects their practice and to participate in ethical

References
American Nurses Association (2001) Code of Ethics for Nurses with Interpretive Statements. ANA, Silver Spring MD. Canadian Nurses Association (2002) Code of Ethics for Registered Nurses. CNA, Ottawa. Beauchamp TL, Chlidress JF (2001) Principles of Biomedicai Ethics. Fifth edition. Oxford University Press, Oxford. Internationai Councii of Nurses (2006) The ICN Code of Ethics for Nurses. ICN, Geneva. Lister S (2005) Five-year waits in IVF postcode lottery, www.timesonline.co.uk/ tol/news/ul</article525845.ece. (Last accessed: April 2 2007.) iVIoore L, Savage J (2002) Participant observation, informed consent and ethical approval. Nurse Researcher. 9, 4, 58-69. Nursing and iMidwifery Councii (2004) The NMC Code of Professionai Conduct: Standards for Conduct, Performance and Ethics. NMC, London. Reviil J (2006) Both have cancer But why can't one get the best care? http://observergLiardian. co.uk/uk_new5/story/0,,1816284,00.html #article_continue. (Last accessed: April 2 2007) Toynbee P (2006) Cardinals, bishops and doctors must not deny us our last rights. www.guardian.co.uk/commentisfree/story /0,,1773203,00.html (Last accessed: April 2 2007) Wiison G (2006) Should doctors help patients to die? www.telegraph.co.uk/ news/main.jhtml?xml=/news/2006/05/12 /neuthl2.xml (Last accessed: April 2 2007) Woods M (2005) Nursing ethics education: are we really delivering the good(s)? Nursing Ethics 12,1, 5-18. Woodward W (2006) Lords vote to block assisted suicide bill for terminally ill. www.guardian.co.uk/guardianpolitics/stor y/0,,1773880,00.html (Last accessed: April 2 2007) Worid Medical Association (2005) Medical Ethics Manuai. VJMK FerneyVoltaire, France. Furtiier reading Britisii iVIedical Association (2004) Medicai Ethics Today: The BMA's Handbooi< of Ethics and Law. BMJ Books, London. Hendricic J (2004) Foundations in Nursing and Heaith Care: Law and Ethics. Nelson-Thornes, Cheltenham. iVIason KT, Laurie GJ (2005) Mason & McCail-Smith's Law and Medicai Ethics. Seventh edition. Oxford University Press, Oxford. Thompson IE, Meiia KiVI, Boyd KiVI, Horsburgh D (2006) Nursing Ethics. Fitth edition. Churchill Livingstone, Oxford. Tingie J, Cribb A (Eds) (2002) Nursing Law and Ethics. Second edition. Blackwell Science, Oxford.

46 aprii 18 :: vol 21 no 32 :: 2007

NURSING STANDARD