44 unit 1 | Professional Considerations
the exactness of the law (Macklin, 1987). Here is an
example:
Mrs. Van Gruen, 82 years old, was admitted to the
hospital in acute respiratory distress. She was diag-
nosed with aspiration pneumonia and soon became
septic, developing adult respiratory distress syn-
drome. She had a living will, and her attorney was
her designated health-care surrogate. Her compe-
tence to make decisions was uncertain because of her
illness. The physician presented the situation to the
attorney, indicating that without a feeding tube
and tracheostomy Mrs. Van Gruen would die.
According to the laws governing living wills and
health-care surrogates, the attorney could have
made the decision to withhold all treatments.
However, he believed he had an ethical obligation to
discuss the situation with his client. The client
requested that the tracheostomy and the feeding tube
be inserted, which was done.In some situations, two or more principles may
conflict with each other. Making a decision under
these circumstances is very difficult. Following are
several of the ethical principles that are most
important to nursing practice—autonomy, non-
maleficence, beneficence, justice, confidentiality,
veracity, and accountability—and a discussion of
some of the ethical dilemmas that nurses encounter
in clinical practice.
Autonomy
Autonomy is the freedom to make decisions for
oneself. This ethical principle requires that nurses
respect patients’ rights to make their own choices
about treatment. Informed consent before treat-
ment, surgery, or participation in research is an
example. To be able to make an autonomous choice,
individuals need to be informed of the purpose,
benefits, and risks of the procedures to which they
are agreeing. Nurses accomplish this by providing
information and supporting patients’ choices.
Closely linked to the ethical principle of auton-
omy is the legal issue of competence. A patient
needs to be deemed competent in order to make a
decision regarding treatment options. When
patients refuse treatment, health-care personnel
and family members who think differently often
question the patient’s “competence” to make a deci-
sion. Of note is the fact that when patients agree
with health-care treatment decisions, rarely is their
competence questioned (AACN News, 2006).
Nurses are often in a position to protect a
patient’s autonomy. They do this by ensuring that
others do not interfere with the patient’s right to
proceed with a decision. If a nurse observes that a
patient has insufficient information to make an
appropriate choice, is being forced into a decision,
or is unable to understand the consequences of the
choice, then the nurse may act as a patient advocate
to ensure the principle of autonomy.
Sometimes nurses have difficulty with the prin-
ciple of autonomy because it also requires respecting
another’s choice, even if the nurse disagrees with it.
According to the principle of autonomy, a nurse
cannot replace a patient’s decision with his or her
own, even when the nurse honestly believes that the
patient has made the wrong choice. A nurse can,
however, discuss concerns with patients and make
sure patients have thought about the consequences
of the decision they are about to make.Nonmalef icence
The ethical principle of nonmaleficence requires
that no harm be done, either deliberately or unin-
tentionally. This rather complicated word comes
from Latin roots:non, which means not;male
(pronounced mah-leh), which means bad; and
facere,which means to do.
The principle of nonmaleficence also requires
that nurses protect from danger individuals who
are unable to protect themselves because of their
physical or mental condition. An infant, a person
under anesthesia, and a person with Alzheimer’s
disease are examples of people with limited ability
to protect themselves. Nurses are ethically obligat-
ed to protect their patients when the patients are
unable to protect themselves.
Often, treatments meant to improve patient
health lead to harm. This is not the intention of the
nurse or of other health-care personnel, but it is a
direct result of treatment. Nosocomial infections as
a result of hospitalization are harmful to patients.
The nurses did not deliberately cause the infection.
The side effects of chemotherapy or radiation ther-
apy may result in harm. Chemotherapeutic agents
cause a decrease in immunity that may result in a
severe infection, whereas radiation may burn or
damage the skin. For this reason, many patients opt
not to pursue treatments.
The obligation to do no harm extends to the
nurse who for some reason is not functioning at an
optimal level. For example, a nurse who is impaired