Ethics in perioperative practice—principles and applications

AORN Journal,  April, 2002  by Kathryn Schroeter

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Editor's note: This is the first in o nine-pod series that explores the effect the American Nurses Association's (ANA's) Code of Ethics for Nurses with Interpretive Statements has on perioperative nurses. Each article in this series with one with one of the nine provisions outlined in the ANA code, along with interpretations and examples for perioperative nurses. At the conclusion of this series, perioperative explications of the ANA code will be included in AORN's 2003 Standards, Recommended Practices, and Guidelines.

Perioperative nurses often find ethical decisions difficult to make, but necessary when caring for surgical patients in practice. Perioperative nurses need to be able to recognize ethical dilemmas and take appropriate action as warranted. They are responsible for nursing decisions that are not only clinically and technically sound but also morally appropriate and suitable for the specific problems of the particular patient being treated. The technical or medical aspects of nursing practice answer the question, "What can be done for the patient?" The moral component involves the patient's wishes and answers the question, "What ought to be done for the patient?" (1)

AORN's Ethics Task Force has detailed specific perioperative nursing explications that correspond to the nine provisions in the American Nurses Association's (ANA's) Code of Ethics for Nurses with Interpretive Statements. (2) The ANA's code of ethics expresses the moral commitment to uphold the goals, values, and distinct ethical obligations of all nurses. Nursing is practiced in a changing social context, so this code of ethics has become a dynamic document.

The ANA code and AORN's explications for perioperative nurses provide the framework in which perioperative nurses can make ethical decisions. (3) The code establishes a nonnegotiable ethical standard for the nursing profession. It demonstrates accountability and responsibility to the public, other members of the health care team, and the profession overall. This series of articles will help perioperative nurses relate the ANA code to their own area of practice and provide examples of behaviors that reflect the ethical obligations of perioperative nurses.

BIOETHICAL PRINCIPLES

According to the ANA, the term ethical refers to reasons individuals have for the decisions they make about how they ought to act. The term moral overlaps the term ethical, but it is more aligned with an individual's personal beliefs and cultural values. (4) Underlying nurses' ethical actions are the principles of bioethics, which have a great deal of influence on perioperative nursing practices. These principles include

* autonomy (ie, an individual's self-determination), which is the principle that encompasses respect for others, and allows individuals to make voluntary, uncoerced decisions about life situations;

* beneficence, which is the principle of doing good, benefiting, or acting in the best interests of the patient--health care providers strive to do this for their patients;

* nonmaleficence, which is the principle that directs health care providers to do no harm--it often is not enough to do good for a patient, nonmaleficence also must be considered proportionally when heath care decisions are being made;

* justice, which is the principle that treats individuals according to what is fair or owed to them (ie, patients expect to be treated fairly and to receive equal care);

* fidelity, which is the principle of keeping promises, as patients expect health care providers will keep their promises to maintain the confidentiality and privacy of patient information; and

* veracity, which is the principle of truth telling--patients expect health care providers to be truthful about their care. (5)

These principles often come into conflict with the values of those involved in ethical decision making. It may be difficult for patients, nurses, and other health care providers to prioritize between principles because the context of each situation may vary.

RESPECT FOR PEOPLE

Provision 1 in the Code of Ethics for Nurses with Interpretive Statements reads:

   The nurse, in all professional relationships, practices with compassion and
   respect for the inherent dignity, worth and uniqueness of every individual,
   unrestricted by considerations of social or economic status, personal
   attributes, or the nature of health problems. (6)

This provision clarifies that perioperative nurses should have respect for human dignity, especially in the context of their relationships with patients and taking into account the nature of patients' health problems. Nurses also should respect human dignity in their relationships with their colleagues and others in the health care setting. This provision also addresses the right of patients and nurses to self-determination. In terms of behavior, the overall concept expressed is respect for people.

SUPPORTING PATIENT RIGHTS AND CHOICES

Perioperative nurses are obligated morally to respect the dignity and worth of individual patients. Perioperative nursing care must be provided in a manner that preserves and protects patient autonomy and human fights. Nurses have an obligation to be knowledgeable about the moral and legal rights of their patients and to protect and support those rights. Health care does not occur in a vacuum, so perioperative nurses must take into account both individual rights and interdependence in decision making. By doing so, nurses can recognize situations in which individual rights to self-determination in health care temporarily should be overridden to preserve the life of the human community. For example, during a bioterrorism attack, victims infected with transmissible organisms (eg, small pox) require infection control measures to prevent transmission to others.