Autonomy implies the freedom to make choices and decisions about one’s own care without interference, even if those decisions are not in agreement with those of the health care team. This principle assumes rational thinking on the part of the individual and may be challenged when the individual infringes on the rights of others.

For example, you use this principle when deciding what nursing interventions should be provided for patients who are dying when some of those interventions may cause pain. In the course of prolonging life, harm sometimes occurs.

Is it harmful to accept an assignment to “float” to an unfamiliar area that requires the administration of unfamiliar medications?

Fidelity involves keeping information confidential and maintaining privacy and trust (e.g., maintaining patient confidentiality regarding a positive HIV test or “blowing the whistle” about unscrupulous billing practices).

This principle involves the allocation of scarce and expensive health care resources. Should uninsured patients be allowed to use the emergency department (ED) for nonemergency care—the most expensive route for delivering this type of care? Who should be paying for their care?

The principle of veracity may become an issue when a patient who suspects that her diagnosis is cancer asks you, “Nurse, do I have cancer?” Her family has requested that she not be told the truth, because their culture believes bad news takes away all hope for the patient.

Derived from Judeo-Christian origins, the deontological normative approach is duty-focused and centered on rules from which all action is derived. The rules represent beliefs about intrinsic good that are moral absolutes revealed by God. This approach reasons that all persons are worthy of respect and thus should be treated the same.

Derived from humanistic origins, the teleological approach is outcome-focused and places emphasis on results. Good is defined in utilitarian terms: That which is useful is good. Human reason is the basis for authority in all situations, not absolutes from God. Morality is established by majority rule, and the results of actions determine the rules. Because results become the intrinsic good, the individual’s actions are always based on the probable outcome.

Derived from humanistic and Judeo-Christian influences and most commonly credited to Joseph Fletcher (1966), an Episcopalian theologian, the situational view holds that there are no prescribed rules, norms, or majority-focused results that must be followed. Each situation creates its own set of rules and principles that should be considered in that particular set of circumstances. Emphasizing the uniqueness of the situation and respect for the person in that situation, Fletcher appeals to love as the only norm. Critics of this approach argue that this can lead to a “slippery slope” of moral decline.

Make sure you collect enough data to give yourself an accurate picture of the issue at hand. When the facts of a situation become known, you may or may not be dealing with an ethical issue.

In the ICU scenario, if competent patients have expressed their wishes about resuscitation, this should be reflected in the chart. If a living will has been executed and is recognized as valid within your state, its presence in the chart lends considerable weight to the decision. The patient should be encouraged to discuss his or her decision with family to decrease the chances for disagreement if and when the patient can no longer “speak” for himself or herself. If immediate family members disagree with the living will, the physician may be reluctant to honor it, at least in part because of concern regarding possible liability. If a living will is executed without prior or subsequent discussion with the attending physician, there may be reluctance to honor the will, because the physician was not informed of the patient’s decision. The physician may feel that the patient did not make an informed decision. However, a durable power of attorney for health care (DPAHC), combined with a living will completed before the patient’s present state of incapacitation, would stand as clear and convincing evidence of the patient’s wishes, preventing such a problem. The example of extraordinary care in the ICU illustrates the existence of values and principles in conflict. When the care team, family, and patient have different views of the situation, the patient is likely to be burdened with less than the best outcome, unless differences are resolved. The nurse can facilitate communication between the family and patient in resolving differences among all those involved. In this situation, the ethical components of this second step involve autonomy and fidelity versus beneficence.

Having collected data and after having attempted to discuss the issue with all involved parties, you are faced with the following three options:

In the ICU scenario, did improved communication occur among patients, families, and physicians? Were your efforts to advocate met with resistance or a rebuff? What could you try differently the next time? What values or principles were considered most important by the decision makers? What kind of assistance did you receive from the IEC? What role did nursing play in this situation, and was it appropriate?