Ethics Applied to Nursing: Personal Versus Professional Ethics

Morals are concerned with dealing with right or wrong behavior (conduct) and character. The terms ethics and morals are difficult to define separately. Morals comes from a Latin root, and ethics comes from a Greek root. Both words mean “customs” or “habits” and refer to the general area of rights and wrongs. The words are often substituted for each other. Ethics and morals are used in the same way in this chapter.

Values involve the worth you assign to an idea or an action. Values are freely chosen and are affected by age, experience, and maturity. A child usually embraces family values during childhood. The teen years are a time of trying out family values and either incorporating them or rejecting and replacing them with new values. Values continue to be modified throughout your lifetime as you acquire new knowledge and experience. Based on changes in values, one’s code of ethics/morals can shift (e.g., organ transplants after you have learned about or cared for a client who receives a transplant).

Law is thought of as a minimum ethic that is written and enforced. As a licensed practical nurse/licensed vocational nurse (LPN/LVN), the Nurse Practice Act in your state is your final authority on what you are legally obligated to do as a nurse regardless of where you are employed (see Chapter 7 for more about nursing and the law). It is essential to have a thorough knowledge of the Nurse Practice Act in the state in which you are employed.

Nursing ethics are similar to, but also different from, the legal aspects that regulate your nursing practice. Table 6.1 presents a comparison of legal aspects and nursing ethics.

As nursing theories emerged, so did the nursing process and critical thinking, and nursing textbooks began to include these topics. Nurses discovered that in addition to their dependent role to health care providers, they had something special to contribute to the client. Finally, it was understood that the client was a person, not just a disease. With the help of the nursing process, nurses had a way to identify additional needs that could be responded to through nursing care. Rather than expecting clients to blindly follow orders because “we know what is wrong with you and we can fix it” (benevolent paternalism), clients were encouraged to be an active part in planning and implementing their own nursing care plan (support of client autonomy). Today, the availability of evidence-based resources on the Internet has contributed to client autonomy.

Despite what we observe today, changes in nursing did not happen easily. Many nurses were entrenched in their dependent role to health care providers, and they believed that nursing was being ruined by the changes that were taking place. Nursing textbooks and curricula, however, both had to change to reflect the nursing process, critical thinking, and a focus on the total client (not just the physically diseased or injured portion of the client). Adding the nursing process and critical thinking changed the nursing role and nursing philosophy. Nurses, both LPNs/LVNs and registered nurses (RNs), are not just “doers” but also “thinkers.” The nursing process and critical thinking empowered nurses. This in turn influenced a change in nursing ethics.

Ethical principles in this chapter are about application of nursing ethics to nursing decisions and action. You are encouraged to look at both sides of an ethical principle. Recognize that no principle applies in the same way to all clients and their unique situation. No principle is absolute.

Critical thinking (see Chapter 5) plays a major role in sorting out ethical choices and legal responsibilities in regard to the client. The client’s knowledge of choices regarding care also affects ethical decision-making.

Health agencies such as hospitals, hospice units, and long-term care settings have an ethics committee. This multidisciplinary team (e.g., nurses, health care providers, clergy, social worker, and other allied health members) assists with difficult ethical decisions. Usually the discussions relate to new or unusual ethical questions. The recommendations of the ethics committee are expected to be given serious consideration by all stakeholders. In a faith-based organization, the principles of the faith can be anticipated to impact the decision-making of this committee. However, if you think the ethics committee makes all the medical ethical decisions, you are only partially right. Clients arrive with their culture-based and/or religion-based ethics, which were often established long before they were born. What the person can and cannot do in regard to health care has already been established by the culture of which they are a part. See Chapters 10 and 11 for a discussion of cultural and spiritual needs, spiritual caring, and religious differences.

In the Western secular belief system, the emphasis is shifted from duties to the rights of the individual. This system has the following characteristics:

Numerous bills of rights have been written, and fierce debates have taken place at both state and national levels. The question of individual autonomy and individual rights is far from being settled. Recently, some laws based on individual autonomy and rights have been passed (e.g., Health Care Reform; death with dignity laws). However, attempts to rescind laws that have been passed continue. The question is: To what extent do one’s individual moral decisions (rights) get in the way of another’s moral autonomy?

Nightingale is referring to the ethical principle nonmaleficence, which comes from the Latin primum non nocere, meaning “first do no harm.” Nonmaleficence is the basis of many of the “rules” promoted by your instructors, such as the following:

If the principle of nonmaleficence is taken to the extreme, however, SPNs/SVNs and LPNs/LVNs would not be able to perform many nursing duties. Few beneficial treatments are entirely without harm, including the following:

Each of the preceding procedures has the potential for doing good and doing harm. The question always is how to do the least amount of harm when doing something that is expected to result in good. The obvious answer is to never knowingly participate in any action that will deliberately harm the client. The client must also have agreed to the procedure verbally or in writing, depending on the procedure (autonomy). This is a reason for practicing procedures in the nursing lab; preparing for nursing care; reviewing your nursing care plan with the instructor; and reviewing action, side effects, and dosage with the instructor before giving a medication.

The following are negative examples of nursing actions that were meant to do no harm but resulted in injury:

Beneficence means to “do good” with your nursing actions and is the basis of trust in nursing. It also involves preventing harm and removing harm. You have read how nonmaleficence and beneficence are often difficult to separate and may go hand in hand. The following major nursing duties to the client are associated with beneficence:

Potter, Perry, and Stockert (2017) describe autonomy as respecting a client’s independence and right to determine a course of action. However, autonomy does not mean that clients can do whatever they want. Autonomy means the following:

Yoder-Wise (2019) describes autonomy as follows:

We expect people to respect our rights, and we respect their rights as long as their rights do not interfere with someone else’s rights.

There is also a fine line between autonomy and abandonment. Excessive control means interfering too much in a client’s life. Not interfering enough results in neglect of the client. Here are some examples:

More information is needed in both situations to determine if more or less interference is recommended.

Fidelity challenges each practical/vocational nurse to be faithful to the charge of acting in the client’s best interest when the capacity to make free choice is no longer available to the client. This does not include rescuing behaviors and becoming paternalistic in making decisions for vulnerable clients (legal competency will be described in Chapter 7). As a nurse, you must differentiate between your feelings and choices regarding an issue and the feelings and wishes of the client. These points are foremost in making a decision. Charting the client’s feelings and wishes as expressed, without your personal interpretation, provides information for the health care provider when important decisions need to be considered. Examples of breaching fidelity include the following:

You alone make the decisions regarding what you do when you are away from the clinical area and the immediate support and supervision of the instructor. In a sense, fidelity sits on your shoulder, to ignore or to embrace. To ignore creates an ethical dilemma and a potential legal consequence. Dismissal from school or termination from a job can be the end result.

Justice means that SPNs/SVNs and LPNs/LVNs must deliver fair and equal treatment to all clients, recognizing and avoiding personal bias. For example, each client with the same diagnosis should receive the same level of care. Being fair does not mean giving every client the same things. It means treating them all the same (i.e., with dignity and respect). As a nurse, you make daily decisions to provide the highest quality of care possible.

Personal bias can cloud our vision as nurses. Identifying hidden bias can assist the LPN/LVN in providing justice to all clients. For example, if the clients on your floor in the hospital represent different levels of wealth, social status, culture, religion, and moral and value systems, but all of them are acutely ill.

Consider the client who has Kaposi sarcoma, a defining component of AIDS. Do you classify AIDS as a life-threatening illness or as a retribution for behaviors you consider immoral? If your personal ethics interfere with the care you give, you may find yourself giving this client more time than needed and doing less than needed for other acutely ill clients or providing minimal care for the client and lavishing attention on those who “deserve the care.”

Consider a young, single mother who has five children and just found out she is pregnant. How you proceed can be impacted by a personal bias, assuming that she should have prevented this pregnancy. All clients must be treated equally. This is your ethical duty.

It is within your power to make decisions about daily issues related to justice. Be careful to hear hidden bias within yourself: “They are so young; so much living left to do”; “They had a full life already”; “They are an alcoholic; never took care of their kids”; and so on. Identifying a bias will assist you in providing “just” care. Visit the following website to identify your hidden biases: https://implicit.harvard.edu/implicit/

As an SPN/SVN, you report clients’ comments regarding ethical matters to the RN. Final ethical decisions are not within the LPN/LVN scope of nursing practice. Recall also that ethics is what you ought to do; law is what you have to do.

Advocacy for women remains an important responsibility. As a nurse, speak up when you see decisions being made based on incomplete information (e.g., the health care provider or other health care worker not really listening to a female client). Review Chapter 9 regarding assertiveness and your responsibility. It reminds you that an aggressive, rude approach does not gain you anything except a bad reputation among your peers and clients. Practice assertiveness and remember that change will occur slowly. Many female clients are already experiencing a change and assertively stating their needs. Nurses who advocate for their female clients assist in this process of reducing a paternalistic attitude toward women, one client at a time, as the need arises.