The term autonomy is derived from the Greek words auto (“self”) and nomos (“law”) and refers to the right of self-determination (Tong, 2007). Laws have been enacted to protect the patient’s right to make choices independently. Federal mandates, such as those dealing with informed consent, must be evident in every application for federal funding to support biomedical research. The local IRBPHS assumes the role of judge and jury to ascertain adherence to this enforceable regulation (Dickey, 2006).

The Patient Self-Determination Act (PSDA), which was passed by Congress in 1991 (Ulrich, 1999), is a clear example of the principle of autonomy enacted into law. Any healthcare facility, including acute- and long-term care institutions, surgery centers, HMOs, hospices, or home care, that receives Medicare and/or Medicaid funds, must comply with the PSDA. This law requires that, either at the time of hospital admission or prior to the initiation of care or treatment in a community health setting, “every individual receiving health care be informed in writing of the right under state law to make decisions about his or her health care, including the right to refuse medical and surgical care and the right to initiate advance directives” (Mezey, Evans, Golob, Murphy, & White, 1994, p. 30). Although ultimate responsibility for discussing treatment options and a plan of care and obtaining informed consent rests with the physician, these authors readily acknowledge the nurse’s responsibility to ensure informed decision making by patients, which includes but is certainly not limited to advance directives (e.g., living wills, durable power of attorney for health care, and designation of a healthcare agent). Evidence of such instruction must appear in the patient’s record, which is the legal document validating that informed consent took place.

One principle worth noting in the ANA’s Code of Ethics addresses collaboration “with members of the health professions and other citizens in promoting community and national efforts to meet the health needs of the public” (New York State Nurses Association, 2001, p. 6). This principle certainly provides a justification for patient education both within and outside the healthcare organization. It provides an ethical rationale for health education classes open to the community, such as childbirth education courses, smoking cessation classes, weight reduction sessions, discussions of women’s health issues, and positive interventions for preventing child abuse. Although health education per se is not an interpretive part of the principle of autonomy, it certainly lends credence to the ethical notion of assisting the public to attain greater autonomy when it comes to matters of health promotion and high-level wellness. In fact, consistent with the Model Nurse Practice Act (ANA, 1978), all contemporary nurse practice acts contain some type of statements identifying health education as a legal duty and responsibility of the registered nurse.

An additional moral framework through which to view the practice of patient education is a framework of expansion of patient capabilities (Redman, 2008). The reason to view expansion of capabilities as a moral enterprise is that capabilities of, say, healthfulness, self-care, and engaging in life, relationships, and pursuits, “have value in themselves and are of special importance in making possible any choice of a way of life” (p. 815).

Another example of autonomy is the development and use of patient decision aid interventions that are designed to assist clients to make
informed treatment choices (Bekker, 2010). These patient decision aids, which include printed materials, videos, and interactive Web-based tutorials, provide clients with information about specific health issues, particular diagnoses, treatment risks and benefits, and questionnaires to determine whether clients need more information. “The emphasis on collaboration between providers and patients on decision making has, in turn, stimulated the development of tools to help patients and their families participate in clinical discussions and reach decisions that incorporate personal values and goals” (Wittmann-Price & Fisher, 2009).

Veracity, or truth telling, is closely linked to informed decision making and informed consent. The landmark decision by Justice Benjamin Cardozo (Schloendorff v. Society of New York Hospitals, 1914) identified an individual’s fundamental right to make decisions about his or her own body. This ruling provides a basis in law for patient education or instruction regarding invasive medical procedures. Nurses are often confronted with issues of truth telling, as was exemplified in the Tuma vs. Board of Nursing case (Rankin & Stallings, 1990). In the interest of full disclosure of information, the nurse (Tuma) had advised a patient with cancer of alternative treatments without consulting the client’s physician. Tuma was sued by the physician for interfering with the medical regimen that he had prescribed for care of this particular patient. Although Tuma was eventually exonerated from professional misconduct charges, the case emphasizes a significant point of law to be found in the New York State Nurse Practice Act (New York State Nurses Association, 1972): “A nursing regimen shall be consistent with and shall not vary from any existing medical regimen.” However, others insist that failure to instruct the patient properly relative to invasive procedures is tantamount to battery (Creighton, 1986). Therefore, in some instances, the nurse may find himself or herself in a double bind. If in such a dilemma, the nurse has a variety of actions available. Two possibilities would be to inform the physician of the professional double bind and engage with him or her in achieving a course of action that best meets the patient’s medical needs while respecting the patient’s autonomy; and to seek out the institutional ethics committee or an ethics consultant for assistance in negotiating interactions with both the physician and the patient.

Cisar and Bell (1995) address this concept of battery related to medical treatment and offer the following explanation of the four elements making up the notion of informed consent that are such vital aspects of patient education:

1. Competence, which refers to the capacity of the patient to make a reasonable decision.

2. Disclosure of information, which requires that sufficient information regarding risks and alternative treatments—including no treatment at all—be provided to the patient to enable him or her to make a rational decision.

3. Comprehension, which speaks to the individual’s ability to understand or to grasp intellectually the information being provided. A child, for example, may not yet be of an age to understand any ramifications of medical treatment and must, therefore, depend on his or her parents to make a decision that will be in the child’s best interest. Similarly, for an adequate informed consent conversation, all options must be expressed in a language the patient can understand and in lay terms.

4. Voluntariness, which indicates that the patient has made a decision without coercion or force from others.

Although all four of these elements might be satisfied, the patient might still choose to reject the regimen of care suggested by healthcare providers. This decision could be the result of the exorbitant cost of a treatment or it might reflect certain personal or religious beliefs. Whatever the underlying motivation, it must be recognized by all concerned that a competent, informed client cannot be forced to accept treatment as long as he or she is aware of the alternatives as well as the consequences of any decision (Cisar & Bell, 1995).

Finally, a dimension of the legality of truth telling relates to the role of the nurse as expert witness. Professional nurses who are recognized for their skill or expertise in a particular area of nursing practice may be called on to testify in court on behalf of either the plaintiff (the one who initiates the litigation) or the defendant (the one being sued). In any case, the concept of expert testimony speaks for itself. Regardless of the situation, the nurse must always tell the truth and the patient (or his or her healthcare agent) is always entitled to the truth (Hall, 1996).

Confidentiality refers to personal information that is entrusted and protected as privileged information via a social contract, healthcare standard or code, or legal covenant. When this information is acquired in a professional capacity from a patient, healthcare providers may not disclose it without consent of that patient. If sensitive information were not to be protected, patients would lose trust in their providers and would be reluctant to openly share problems with them or even seek medical care at all.

A distinction must be made between the terms anonymous and confidential. Information is anonymous, for example, when researchers are unable to link any subject’s identity in the medical record of that person. Information is confidential when identifying materials appear on subjects’ records but can be accessed only by the researchers (Tong, 2007).

Only under special circumstances may secrecy be ethically broken, such as when a patient has been the victim or subject of a crime to which the nurse or doctor is a witness (Lesnick & Anderson, 1962). Other exceptions to confidentiality occur when nurses or other health professionals suspect or are aware of child or elder abuse, narcotic use, legally reportable communicable diseases, gunshot or knife wounds, or the threat of violence toward someone. To protect others from bodily harm, health professionals are legally permitted to breach confidentiality.

In the case of communicable diseases, patients should not be forced or coerced to name their contacts, again because respecting confidentiality maintains trust between the patient and the nurse. But is it fair to deprive a vulnerable spouse or other contact of this important health information? Is it morally acceptable to put one person’s rights above those of another? In some situations, yes, although these decisions are best considered after much deliberation with the patient and other trusted health professionals. Of course, if a patient discloses the identity of his or her contacts, health professionals are mandated to inform them in accordance with applicable state laws. If a patient tests positive for HIV/AIDS, for example, and has no intention of telling his or her spouse about this diagnosis, the physician has an obligation to warn the spouse directly or indirectly (i.e., through anonymous lab reporting) of the risk of potential harm (Tong, 2007).

Adequate deliberation with the patient and others can reveal circumstances in which the reality is even more complex. For example, if the physician or other primary healthcare provider explores the patient’s rationale for not wanting to inform his or her spouse of the infectious disease status, it may be out of fear of inciting domestic violence. According to Brent (2001), “this area of legislation concerned with health care privacy and disclosure reveals the tension between what is good for the individual vis-à-vis what is good for society” (p. 141).

The 2003 updated Health Insurance Portability and Accountability Act (HIPAA) ensures nearly absolute confidentiality related to dissemination of patient information, unless the patient himself or herself authorizes release of such information (Kohlenberg, 2006). One goal of the HIPAA policy, first enacted by Congress in 1996, is to limit disclosure of patient healthcare information to third parties, such as insurance companies or employers. This law, which requires patients’ prior written consent for release of their health information, was never meant to interfere with consultation between professionals but is intended to prevent, for example, “elevator conversations” about private matters of individuals entrusted to the care of health professionals. In a technologically advanced society such as exists in the United States today, this law is a must to ensure confidentiality (Tong, 2007). Currently, in some states and under certain conditions, such as death or impending death, a spouse or members of the immediate family can be apprised of the patient’s condition if this information was previously unknown to them. Despite federal and state legislation protecting the confidentiality rights of individuals, the issue of the ethical/moral obligation of the patient with HIV/AIDS or genetic disease, for example, to voluntarily divulge his or her condition to others who may be at risk remains largely unresolved (Legal Action Center, 2001).