Commentary: nurses should recognise patients' rights to autonomy

British Medical Journal, March 21, 1998 by Pippa Gough

When people become dependent on others for care, their choices and actions may be affected and channelled by their carers' moral judgments and values about what is good and right Although this extends across daily living, it is brought into sharp focus in relation to two key areas--the choice to break the law and the freedom to have sex as one wishes.

Although the case of Mr K highlights the former, in this instance the desire to use illegal drugs, the issues raised are equally applicable to the second area concerning sex and sexuality. Ultimately, we are discussing the principles underpinning the patient's right to autonomy and the nurse's obligation to maintain and promote this.

Patients' autonomy underpins professional practice

Nursing has struggled as much as any of the professions to shake off the practices of paternalism, the creation of dependency, and coercion, however subtly or benignly these are presented. We have probably been successful in raising the debate even if we have not influenced completely the way we deliver care.

The nurses' code of professional conduct, which provides the fundamental framework for professional practice, has strongly influenced these changes.(1) Recognition of a patient's autonomy underpins the code. At its most fundamental, this means respecting individuals' choices concerning their lives and, where necessary, providing an environment of privacy and confidentiality so that these choices can be pursued.

Personal privacy and public peril

The limitations to a nurse's duty of care in this respect are tempered only by the balance between the protection of personal privacy and the threat of public peril. In other words, this duty of care extends beyond the individual to society, and nurses are accountable for their actions in terms of each. The dividing line between the two, however, is rarely clear and dilemmas abound. Moreover, the nurse's own values may colour his or her interpretation of what might infringe the public interest, especially if this involves unlawful activity.

In the case of Mr K, the possible consumption of cannabis within the ward, which is after all his home during the respite period, does not seem to threaten the public interest in the slightest. Protection of Mr K's privacy therefore remains paramount. The nurses involved are not sure that cannabis is being consumed, and as this knowledge might affect their legal position, they should investigate no further unless this may present problems in respect of potentially harmful drug interactions. They should respect Mr K's right to consume cannabis if he wishes, and to do so on the ward, without further questions being asked. Promotion of autonomous action in relation to pursuing sexual relationships should be dealt with similarly.

(1) United Kingdom Central Council for Nursing Midwifery and Health Visiting Code of professional conduct. London: UKCC, 1992.

Royal College of Nursing, London W1M 0AB

Pippa Gough, assistant director nursing policy

pippa.gough@ rcn.org.uk