Provisions 1-3 Fundamental Values and Commitments of the Nurse

The fundamentals of nursing ethics, the fundamental values and responsibilities nurses assume, are expressed in the first three provisions of the Code. When nurses need help expressing their primary commitment, that is, what serves as the core of their professional activity, they can find that core commitment outlined in the first three provisions of the Code. These values include nurses' respect for human dignity, nurses' primary commitment to the patient, and nurses' protection of patient privacy.

What does respect for human dignity mean in health care and how will it be demonstrated? The concept of human dignity, flowing from the principle of respect, is expressed in numerous ways when nurses go about their work. The idea is based on the principle of respect for persons and is derived from the philosopher Immanuel Kant's rationalist theory, as well the Judeo-Christian texts, that people should treat others in the same manner in which they desire to be treated: that persons should be treated as ends in themselves, not as means to an end. This attitude translates into respect for all persons.

Respecting all persons means the nurse should honor human dignity in every encounter with every patient and in all encounters with other professionals. For the bedside nurse, this can be expressed in small gestures such as closing curtains for privacy, and in large gestures, such as assuring patient autonomy through the establishment of conditions necessary to provide truly informed consent.

The concept of informed consent is fundamental to the delivery of health care. The nurse's responsibility is paramount in ensuring that patients are fully informed and understand their options. "Each nurse has an obligation to be knowledgeable about the moral and legal rights of all patients to self-determination." (Code of Ethics, p. 8) The nurse does this by assessing the patient's comprehension of the treatment options presented and the implications of each. If the nurse feels that the patient's comprehension is questionable, the nurse enlists the use of a surrogate. In the absence of a surrogate, the nurse does his or her best to ensure that decisions are made in the best interest of the patient, considering "the patient's personal values to the extent that they are known." (Code of Ethics, p. 9)

What if the patient's idea of self-determination includes relying on others for medical decision-making? Is it the nurse's ethical responsibility to enforce individual expressions of autonomy? Should the nurse intervene to enforce his or her concept of autonomy? The Code recognizes that professional nurses encounter an increasingly pluralistic and diverse culture and that individualism can be culturally defined. Some patients may choose to defer to the values of others, such as family or community, as they make decisions. The Code supports this, stating, that "support of autonomy in the broadest sense also includes recognition that people of some cultures place less weight on individualism and choose to defer to family or community values in decision making." (Code of Ethics, p. 9)

There may be times when the nurse is confronted with situations in which the support of autonomy and individual rights may bring severe harm to others, for example, a public health crisis. While supporting patient autonomy is paramount, the Code considers limiting such autonomy appropriate. The Code, however, reminds the nurse that the "limitation of individual rights must always be considered a serious deviation from the usual standard of care" and is justified only as a last resort. (Code of Ethics, p. 9)

With regard to end-of-life care, the Code of Ethics reiterates the obligation to respect all persons and their autonomy. The Code reminds nurses that they are "leaders and vigilant advocates for the delivery of dignified and humane care." (Code of Ethics, p. 9) The prohibition, however, still exists that nurses may never act with the direct intent of ending a patient's life. They may act only to alleviate suffering, albeit with the knowledge that some palliative care may hasten death. Because of the moral distress this kind of nursing care can provoke, nurses are encouraged to learn more about end-of-life care and contribute to the expansion of end-of-life care practices through research, education, practice, and policy development.

The revised Code reflects the changes in health care financing and delivery systems that interfere with the delivery of humane respectful care and pose new possibilities of "conflict between economic self-interest (bonuses, sanctions, and financial incentives) and professional integrity." (Code of Ethics, p. 10) These conflicts are not restricted to clinical practice, but may occur in administration, education or research and be interpersonal or intra-personal in nature. Nurses in all roles are reminded to be aware of such conflicts of interest that may thwart the kind of respectful care nurses have historically given. In a cost-cutting era, it is ethically incumbent upon the nurse in the hospital or in other settings to be sensitive to the potential effects of financial cutbacks and conflicts which may put a patient at risk of sub-standard care in difficult health care settings.

Privacy and confidentiality issues are paramount and may be compromised as health care professionals and others make an assortment of claims to information about a patient's health state. Also, as health care organizations put into place new information technologies required by the Health Insurance Portability and Affordability Act (HIPAA), access to personal information could be compromised. Nurses must be especially aware of changes in hospitals' charting and record-keeping mechanisms and alert the appropriate individuals when privacy and confidentiality safeguards appear to be threatened.

Given these new complexities, how do nurses keep the patient as their primary commitment when so many take part in the care of the patient? They do this by recognizing that nursing is accomplished "through the interdependence of nurses in differing roles and working to make sure that all relevant parties are involved and have a voice in decision-making about patient care issues." (Code of Ethics, p. 11) Nurses are not isolated professionals. Creating a health care delivery system responsive to patients' and society's needs will not be achieved by one nurse alone. The Code provides strength to nurses as it reminds them of their membership in the larger professional nursing community.

Research funding is available to test new drugs and therapies. The nurse has a responsibility to ensure patients will be protected if they choose to be part of such a research project. Special concerns are raised when research involves vulnerable populations or individuals, "including children, prisoners, students, the elderly and the poor." (Code of Ethics, p. 13) The Code allows for the nurse to be a conscientious objector with regard to research if he or she questions the ethics of a particular research project. Nurses "have the duty to question and, if necessary, to report and to refuse to participate in research they deem morally objectionable." (Code of Ethics, p. 13) Research nurses must be ever vigilant as universities are experiencing intense pressure to generate the revenue tied to clinical trials.

What may be especially challenging for the bedside nurse is the Code's mandate that nurses be involved in review mechanisms. Nurses are crucial in planning, establishing, implementing, and evaluating review mechanisms that will ensure patient care and safety. This includes being part of peer review committees, credentialing processes, quality assurance procedures and hospital ethics committees. This ability to evaluate not only systems, but fellow colleagues, may prove uncomfortable for nurses, requiring nurse administrators to provide educational opportunities to assist nurses in these responsibilities. Specifically, nurse administrators must ensure that all nurses have access to hospital ethics committees and that ethics committees have nurse representation.

Recently, the Institute of Medicine reported that large numbers of patients have been harmed by medical errors (Institute, 2000). Following that report, the Chicago Tribune reported that medication errors accounted for a large part of the harm caused patients. Nurses have key roles in the safe and accurate administration of medications. (Berens, 2000) Does the Code have anything to say about this issue? The Code is explicit. With respect to medication or other errors, nurses are expected "to follow institutional guidelines in reporting errors committed or observed to the appropriate supervisory personnel and for assuring responsible disclosure of errors to patients." (Code of Ethics, p. 14) However, acknowledging the importance of systems theory, the Code states that nurses are not expected to participate in "punitive responses to errors that exist only to fix blame rather than correct systems conditions that lead to errors." (Code of Ethics, p. 14)

What about sheer incompetence or negligence? The nurse "must be alert to and take appropriate action regarding any instances of incompetent, unethical, illegal or impaired practice by any member of the health care team or the health care system or any action on the part of others that places the rights or best interests of the patient in jeopardy." (Code of Ethics, p. 14) The Code makes an interesting distinction between questionable practice and impaired practice, acknowledging the difference between such things as a self-medicating nurse under a great deal of stress, a colleague who is overtly incompetent due to drug abuse, or an intellectually incompetent practitioner.

According to the Code, "the nurse's duty is to take action designed both to protect patients and to assure that the impaired individual receives assistance in regaining optimal function." (Code of Ethics, p. 15) This is a form of patient advocacy and in some cases may result in whistleblowing. The Code exhorts professional associations to assist and support nurses who may have to take a "whistleblower" course of action, recognizing that nurses often become whistleblowers at their own professional peril.

When the rights of the patient collide with what is best for the patient, nurses may endure considerable moral distress. For example, consider the dilemma of a nurse working on a psychiatric unit specializing in the treatment of teenage patients with anorexia nervosa. The treatment program includes withdrawing rewards from the patients if their weight goes down. The nurse, however, believes, in principle, that people have the right, under most situations, to achieve a weight that they want (Fry, p. 32). However, in this instance, the patient's desired weight is detrimental to her health. Or consider a situation where nurses struggle to balance respect for a patient's desire to ambulate at will on the unit and the risk that this patient will hurt himself (as he has already done) if he climbs out of bed without the assistance of nursing personnel. (Fry, p. 18)