Ethics is sometimes referred to as moral philosophy. It includes the study and decisions involved in determining “right” and “wrong” behavior. Ethics is concerned with “the study of social morality and philosophical reflection on its norms and practices” (Burkhardt & Nathaniel, 2002).

The three main areas of ethics are metaethics, normative ethics, and applied ethics. Metaethics asks questions about the nature of goodness or badness, rather than what is actually good or bad, right or wrong, behavior (Moral Philosophsophy.info, 2005). It focuses on universal truths, where our ethical principles originate, as well as on what these truths mean, and our reasoning. It considers whether there are things that are good or bad independent of us, or whether they are something that we have actually invented. Normative ethics is more about how we should live our lives, good habits that we should adopt, and the consequences of our actions on others. Two types of normative ethics are virtue ethics and deontology. Virtues are considered traits or acts that are good to have, in contrast to vices, which are not. Deontology suggests that certain things are right or wrong, regardless of their consequences. Applied ethics is the practical side of ethics, or the use of ethical principles to determine what is right or wrong for us to do. Applied ethics focuses on the issues and dilemmas that we face, such as abortion, assisted suicide, do not resuscitate, and the right to die.

So where do we get our own personal ethical beliefs? They begin in our formative years with the teachings of parents, relatives, and friends. They are influenced by the religious beliefs that we adopt and hold to be true, by the cultures of which we are a part, and by the education we receive. At the point of entry into nursing, each of us was taught what behaviors were appropriate and expected of us, as well as standards and practices that were considered “professional.” These were intertwined to form a belief system that we use to make ethical decisions. Understanding our own values, acknowledging those values, and understanding where they came from is essential for sound ethical decision making in clinical practice. In order to understand the ethical beliefs and the decisions of patients and families, it is equally important to understand their backgrounds, their cultures (Jecker, 1997), their religions, and their social norms. Without such an understanding, the needs of the patient and family and the interventions by nurses and other health professionals may be in conflict. Consider for a moment how you would approach each patient differently if one is Native American, one is Jewish, one is Islamic, or one was born in the Far East or South America. The backgrounds of these patients may well be different from yours and are certainly different from one another.

Patients and their families cannot be viewed in isolation, and they cannot be approached solely from the perspective of your personal beliefs. They have the right to receive and participate in health care from their own perspectives and their own systems.

“Ethical principles are basic and obvious moral truths that guide deliberation and action” (Burkhardt & Nathaniel, 2002). The eight ethical principles considered here are autonomy, beneficence, nonmaleficence, justice, confidentiality, veracity, fidelity, and privacy.

Autonomy is the quality or state of being self-governing and of having moral independence and self-determination. The patient has a right to make his or her own decisions, assuming the capacity and the ability to do so. This principle is one that frequently causes serious ethical dilemmas in the critical care setting. The patient may be greatly incapacitated, on a ventilator, heavily sedated, and unaware of his or her surroundings or condition. At this point, other people necessarily step in and make decisions that include life and death situations. This places additional moral, emotional, and cognitive demands on the family surrogate (Meeker & Jezewski, 2005). In 2005 the American Association of Critical-Care Nurses (AACN) issued a public policy statement on the role of the critical care nurse as a patient advocate (AACN, 2005). This includes respect and support the patient (or surrogate) in autonomous, informed decision making and to intercede for patients who cannot speak for themselves in situations involving immediate action.

Beneficence is the quality or state of being beneficent (i.e., doing what is good). Nonmaleficence is the counterpart term (i.e., not doing harm). Physicians, nurses, specialty therapists, and clergy are assumed to be beneficent and not to want to intentionally do harm to a patient. The questions, however, are: What is good? What is harm? When does a medical intervention cease to be doing good for a patient and does harm? Such deliberations often stem from or involve ethical dilemmas. For whom is the decision good? To whom will it cause harm? If a patient could receive an experimental drug that might reverse a condition, will it cause harm, and, if it will cause harm, will the harm be exceeded by the good the drug could do? What if the patient prefers to use alternative therapies that are not within the mainstream of medical practice? The terms alternative and complementary are used to refer to nontraditional methods of diagnosing, preventing, or treating a particular disorder. Many cancer patients, for example, may find that these approaches relieve their symptoms or side effects, ease their pain and suffering, and generally enhance their lives during the course of their treatment (ACS, 2006).The patient has the autonomous right to use such therapies. The American Holistic Nurses Association suggests that nurses draw upon and use both conventional and complementary and alternative (CAM) modalities and that both are within the scope of nursing practice (AHNA, 2004). Therefore the use of such approaches not only is within the rights of the patient, it also is appropriate in nursing practice. Ethical questions arise when the patient chooses to use such treatments in lieu of traditional medicine and the nurse is asked to participate in their administration. This can pose a conflict between the patient’s right to autonomous decision making and the nurse’s observance of the principles of beneficence and nonmaleficence.

Experimental procedures can create similar issues. The Oncology Nursing Society has taken a position on cancer clinical trials, indicating that, “Every person diagnosed with cancer must have the right to participate in a clinical trail if medically indicated” (ONS, 2004a). Clinical trials, of course, must follow agency policies regarding informed consent, and patients must be advised of their rights as human subjects, including the risks and benefits of experimental drugs and devices.

The obligation to do good and the obligation not to do harm clearly arise in the issue of assisted suicide, namely, “Any act that entails making a means of suicide available to a patient with knowledge of the patient’s intention” (ONS, 2004b). The ONS statement affirms that any requests for assisted suicide should include an open discussion of the request, but nurses are to uphold the ethical code and standards of the profession and may refuse to participate in any state where assisted suicide is legal. The American Nurses Association’s position statement on assisted suicide reads, “Nursing has a social contract with society that is based on trust and therefore patients must be able to trust that nurses will not actively take human life” and, “Nurse participation in assisted suicide is incongruent with the accepted norms and fundamental attributes of the profession” (ANA, 1994a). Nurses continue to be confronted and struggle with the complex moral and professional issues related to assisted suicide (Scanlon & Rushton, 1996). With regard to active euthanasia, the ANA states, “The nurse should not participate in active euthanasia because such an act is in direct violation of the Code for Nurses with Interpretive Statements” (ANA, 1994b and ANA, 2001). This has recently been made even more clear in the case of two nurses and a physician charged with intentionally ending the lives of patients in the aftermath of Hurricane Katrina (NPR, 2006).

The ethical principle of justice implies that the nurse will be fair and impartial while conforming to truth and reason in decision making. This principle is a key point where issues of ethics and human rights intersect (ANA, 1991a). The principle of justice is particularly important in the use and distribution of critical care resources and services. Does everyone have an equal right to receive the same level and quality of health care? Who should be the recipient of a heart or a lung available for transplant? All these decisions involve not only the high-quality health care available in the United States but also the cost of health care. In 1960, U.S. health care expenditures accounted for about 5% of the gross domestic product (GDP); in 2000, that figure had grown to more than 13% (AHRQ, 2002). This is a higher percentage than in any other country in the world. Health spending in the United States topped $1.8 trillion in 2004, accounting for about 17.3% of the GDP (Fleck, 2006). The health care share of the GDP is expected to increase from 15.3% in 2003 to 18.7% by 2014 (Heffler et al., 2005).

Technology has forever changed the health care landscape. Surgical techniques, vascular access, computerization of complex procedures, genome research, and a variety of medical advances have made interventions possible that previously were not only unavailable but completely unknown. Concerns are heightened when we consider the cost of these interventions, their appropriate use, and the consequences of their use. In the greater health care system, ongoing concern focuses on the availability and distribution of health care dollars, including care for individuals who have limited or no insurance. According to the ANA position statement on ethics and human rights, “Human beings deserve respect as ends in themselves, and therefore, deserve nursing services that are equitable in terms of accessibility, availability, affordability and quality” (ANA, 1991a). In a society in which sophisticated and advanced health care is available, ethical dilemmas will continue to emerge concerning who should be the recipients of available resources.

Confidentiality is the concept of nondisclosure of information that is private, personal, or when disclosure could be harmful to another person. As of 2003, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects any information that identifies an individual and that is not an educational or employment record. Patients have the right to see, copy, and supplement their medical records, and hospitals must have safeguards in place to protect identifying information (Health Privacy Project, 2000). Nurses in oncology and critical care settings are equally responsible under federal law for protecting the privacy and confidentiality of all information pertaining to patients. This means that nurses are forbidden to discuss patients in places such as the lobby, elevators, and cafeterias, as was customary in previous years. This can be very difficult in critical care settings, where the proximity of one patient to another easily lends itself to a violation of the standards. Nevertheless, all precautions must be taken to safeguard the confidentiality of the patient. Privacy and confidentiality have come to the forefront with the developments in technology, such as facsimile machines and wireless computer networks, which have changed the delivery of health care (ANA, 2005). The use of technology creates the potential for unintentional breaches of confidentiality in the transmission of health care information.

Closely related to confidentiality are the principles of veracity, fidelity, and privacy. Veracity refers to truth telling, which has many ramifications in the critical care setting. Nurses are quite passionate about patients’ rights, and, in an absence of truth, nurses find themselves in unethical situations (Turkoski, 2001). Martin (1993) examined the issue of veracity with regard to the four tenets of autonomy, justice, beneficence, and nonmaleficence. She concluded that lying to patients has no moral justification. Yet, when a patient asks, “Am I going to die?” “Do I have cancer?” “Is my son dead?” do you always answer truthfully? How do you make the decision on what to say? Do you tell the patient what the family does not know, or what the family has requested that the patient not be told, even though, at the same time, you feel that the patient has the right to know? Each situation is unique, and decision making is complicated by the beliefs of the patient, the family, the physician, and even society (Blake, 1996).

Fidelity means promise keeping in an ethical context. It is the virtue of faithfulness; being true to our commitments and obligations to others. These commitments relate to the obligations that are implicit in a trusting relationship, including confidentiality and keeping promises. If the family is promised that the patient will not have pain or suffer at the end of his or her life, then the nurse has the responsibility to keep this promise. Nurses “must use effective doses of medications prescribed for symptom control and nurses have a moral obligation to advocate on behalf of the patient when prescribed medication is insufficiently managing pain and other distressing symptoms” (ANA, 2003a). The principle of fidelity is closely related to the principle of autonomy. Failure to keep promises made to others denies them the opportunity to exercise their freedom of choice in the relationship, which limits their autonomy.

Each patient and family has the right to autonomous decision making and respect for their privacy. Allowing them time alone to discuss issues, freeing them from unauthorized intrusion, and providing informed consent are assumed. With the advent of computerized documentation and records, scheduling, reporting of diagnostics, and certainly communications between the patient and other health care professionals, the potential for technologic intrusion into privacy emerged. HIPAA has changed all of that and has directed that patients and families be assured of their privacy. As mentioned, however, in a close physical environment such as a critical care unit, invasion of that privacy can easily occur. The nurse is responsible for protecting privacy and making every attempt to maintain it.

Virtually every discipline and every field of endeavor now has a code of ethics. Psychology, social work, and criminal justice, as well as newspapers, businesses, manufacturing companies, and real estate agencies, all have codes of ethics, but none could be more basic or more critical than the codes of ethics that affect the lives of patients and their families. Two codes of ethics are essential for nurses: the ANA Code of Ethics for Nurses with Interpretative Statements (ANA, 2001) and the International Council of Nurses (ICN) Code of Ethics for Nurses (ICN, 2000). These two documents set forth the ethical standards that nurses are expected to follow and against which their behaviors can be evaluated, including in a court of law. In fact, in 1994 the ANA published a position statement that stated the ANA believes the nine Provisions of the Code are nonnegotiable and every nurse has an obligation to abide by them (ANA, 1994b). Every nurse is responsible for reading, understanding, and keeping readily available copies of the ANA and ICN codes, which can be consulted when difficult situations and ethical dilemmas arise. These documents can be the focus of dialog and reflection, as well as a source of understanding, support, and direction in ethically complex situations.

The Patient Self-Determination Act, which took effect in 1991, applies to all health care institutions and providers (Federal Register, 2003). It requires that all individuals receiving medical care be provided with written information about their rights, including the right to accept or refuse treatment (Kyba, 2002) and the right to have advance directives. They must be made aware of their right to make decisions upon admission (ANA, 1991b). Nurses are responsible for ensuring that the patient is made aware of these rights, unless the patient is incapable of understanding the information or of making a decision, in which case the information goes to the family.

The term advance directive refers to the living will and the health care power of attorney. These give instructions about future medical care if the person is unable to participate in medical decisions because of serious illness or incapacity (NHPCO, n. d.). A living will is a written document in which a patient’s wishes about medical treatment are described so that if the person becomes unable to communicate those wishes, others will do so on his or her behalf. The health care power of attorney is a legal document in which the individual appoints a specific person to make decisions about his or her health care in the event the person becomes unable to make decisions or to communicate personal wishes. An important point is that the states regulate the use of advance directives differently. If the person is hospitalized in a state different from the one in which the papers were signed, their use could be different from that originally anticipated by the patient and family. Nurses need to be aware of hospital policies and state regulations covering advance directives, including do not resuscitate orders (ANA, 2003b). They also need to be in a position to discuss these issues with the patient and the family members responsible for invoking the patient’s wishes. Nurses need to keep in mind that the patient can change these directives at any time, and those changes need to be shared with the family. (See Chapter 13 on end of life care.)

The AACN’s position statement on moral distress states that it occurs when, “You know the ethically appropriate action to take, but are unable to act upon it” and/or “You act in a manner contrary to your personal and professional values, which undermines your integrity and authenticity” (AACN, 2006). The AACN further indicated that in one study nearly 50% of nurses had acted against their consciences in providing care to their terminally ill patients. Moral distress is a serious issue among oncology and critical care nurses (Elpern et al., 2005).

A number of complex and complicated issues contribute to moral distress in the oncology and critical care environments. For example, when no viable medical interventions are left to treat the patient, the decision may be made to withhold further treatments or to discontinue those in place. Either decision can be difficult and extremely traumatic for the families of patients and for the staff (van Rooyen et al., 2005) and can create ethical concerns for nurses. Moreover, a study of 1000 internists found that a large percentage of these physicians would be unwilling to comply with some of patients’ wishes to withhold or withdraw life-sustaining treatment (Farber et al., 2006). This complicates matters even more. Ethics committees are frequently consulted in these situations to provide assistance with decision making and to assist family members, as well as staff members, with their feelings and concerns. One problem is that intentionally withholding life-prolonging treatment may be equated with intentionally causing death and even involve self-deception (Sayers & Perera, 2002). In 1992 the ANA issued a position statement on foregoing nutrition and hydration, a statement that can be very helpful to all nurses. The document states that, “The decision to withhold artificial nutrition and hydration should be made by the patient or surrogate with the health care team.” This should be distinguished from withholding the provision of food and water. The Robert Wood Johnson Foundation suggests that, “Artificial nutrition and hydration is a medical treatment that may be refused [by] any patient who has the ability to make decisions” (RWJF, 2006). In recent years, the inclusion of do not resuscitate orders (ANA, 2003) and artificial nutrition and hydration treatments have become more important in advanced care planning (Gillick, 2006).