Chapter 6: Ethical Commitments and Conflicts

Primary Ethical Commitment

All nurses have only one primary ethical commitment which is to look out for the interests of the patient. The patient is defined in broad terms by the code of ethics since a nurse can be asked to deal with an individual, a family, a social group or even an entire community. While the diseases that inflict patients may turn out to be very similar on a case to case basis, the individual being treated is always unique. Therefore, there may be specific ethical concerns based on the cultural diversity of patients that a nurse has to deal with (ANA, 2001).

The cultural connection between the needs of the patient and the care provided by the nurse becomes very important when the patient comes from a culture that values collective decision making rather than individual opinions. Ethics demand that a nurse should notice the patient's place in his family and the importance of other relationships which a patient might have. This is because at times the wishes of the patient can be in conflict with the wishes of others around him and the nurse might have to step in as a mediator to eliminate the differences (ANA, 2001). If the nurse is unable to reconcile the difference of opinion, it becomes her ethical responsibility to follow the wishes of the patient as much as she possibly can.

The case of Nurse Jake clarifies the ethical principle mentioned above. Nurse Jake was providing care services for a young girl and her very conservative parents did not want the girl to be examined by a male doctor. Jake saw that the patient was showing visible signs of discomfort and was in the need for immediate emergency assistance, but no female doctor was present on duty. Jake made the decision to take the girl to a male doctor and the girl readily agreed to be examined by the doctor. In this case, Jake acted ethically even though he went against the wishes of the family decision makers because Jake had the best interest of the patient in mind.

Conflicts of Interest

While such situations are easy to handle with a simple application of ethical guidelines, problems where a nurse has a conflict of interest are rather more difficult. It has been accepted by the nursing community that conflicts of interest are more common today than they have been in the past and the changed requirements of health care providers as well as health plans for patients can lead to some conflicts as well. However, with respect to patient interests, the more common variety of conflict comes when a nurse sees a difference between her personal values and her professional ethics (ANA, 2001).

For example, a nurse may be firmly against the idea of abortion but she may have to assist in an abortion which is in the interest of the patient. Similarly, a nurse may have moral objections to a certain line of research or even a certain method of research which is otherwise acceptable to the medical community at large. In the first case, the interests of the patient become more important and the nurse has to hold her personal opinions, articles of faith and beliefs to be secondary to the primary requirement of helping those in need, even though she may be an objector to the practice. In the second case, a nurse can object to a research study and even refuse participation if she sees a conflict of interest.

A conflict of interest can also come up with regard to the interest of the patient. For example, on any given day, a patient with a highly contagious disease may wish to refuse treatment and leave the hospital at once (Fry & Veatch, 2000). A nurse who only follows the ethics for the rights of the patient may suggest that the patient should be allowed to leave since his autonomy and the individual right to refuse treatment must be respected at all times.

However, a more pragmatic nurse may recognize that there is a danger to public health if this patient is allowed to leave the hospital environment. In this case, the rights of the public and the greater good for society are more important than the rights given to one person; therefore, the patient should be kept and treated. It must be noted however, that such a conflict of interest is rather rare and generally, any constriction of individual rights is very uncommon in the medical profession and often requires an explanation to higher authorities.

A more complicated example was presented by Fry and Veatch (2000) who gave the example of a nurse working with psychiatric patients. She was responsible for assisting with the treatment of adolescent patients suffering from anorexia nervosa. The disease itself is an eating disorder which is characterized by a self distorted body image as well as a dangerously low weight. Individuals who suffer from this disease may control their weight with dieting to the point of starvation, vomiting food, too much exercise or even resort to drugs for weight reduction.

In the given example, the nurse had to make sure that certain privileges and rewards were to be withdrawn from the patient if their weight goes down. However, the nurse also believed on a personal level that individuals should be allowed to keep whatever weight they want. In this case, the nurse had a personal interest in making sure that the individuals she was dealing with could have their desired weight. However, this was not in the best interest of the patient since the patient's desired weight would be very detrimental in health terms (Fry & Veatch, 2000). The solution to the problem comes from the rule that the nurse has to put the interest of the patient as the primary concern therefore the patients personal wishes as to the ideal weight must be ignored.

Another case can be used to throw some light on conflicting situations as per the case of Nurse Jessica and Charlie X. Charlie was a young boy who felt restricted and claustrophobic in the bed he was placed in and wanted to be able to move about the unit whenever he wished. However, Charlie had hurt himself once while trying to leap out of the bed and Nurse Jessica was faced with the dilemma of confining Charlie and refusing him his rights as a patient (Fry & Veatch, 2000). She considered the case and came to the correct ethical decision that the restrictions on Charlie's movements are for his own benefit as he was asked not to move out of bed without the assistance of a nurse or other medical professional.

A more common conflict of interest can come when a nurse is faced with incentive programs that ask for reduced spending and ethical demands which ask for the best possible treatment (ANA, 2001). Often, a reduction in spending or expenses could be linked with individual bonuses or performance reviews in which case there is a chance of an obvious conflict of interest. The code of ethics (2001) recommends that whenever nurses are faced with such a situation, they should get a clarification of the exact protocols which must be followed from higher authorities so that the spirit of nursing is not harmed.

To better handle actual or perceived conflicts of interest, as well as any other ethical or professional issues being faced by a nurse, the code of ethics (2001) recommends collaborative and cooperative efforts since the overall purpose of health care is to collaborate for a unified cause. However, ethics dictate that collaboration between nurses should be placed within professional boundaries which apply to the relationships between nurses and patients, nurses and the patients' family as well as between nurses and other professionals. It is perfectly understandable that certain situations may blur the boundaries between professional and personal relationships for example:

• Stressful working environments: Stressful situations and working conditions can influence the nurse's ability to maintain professional decorum and can even create bonds of camaraderie which extend beyond acceptable professional relationships.
• Dependence on close colleagues: With continued and long term professional association, an informal nurses club can be formed where members look out for the interests of each other. This loyalty might become dangerous if it extends to hiding errors made by members of the club and not reporting breach of the code of ethics coming from fellow nurses. While loyalty to the field and loyalty to fellow professionals is quite important, excessive or misplaced loyalties can lead to damaging the nursing profession more than helping it.
• Providing prolonged care for a patient: It may happen that a patient develops a close association with a nurse who is providing health care services or that a nurse develops some feelings for the patients under her care. This can lead to the nurse being more considerate of one patient as compared to others under her responsibility, and it may even lead to her giving preferential treatment to one patient, which is certainly against the code of ethics.

In many cases, blurred boundaries can create additional conflicts of interest for a nurse; therefore, an ethical nurse would continue to be professional in her approach and not allow any positive or negative personal feelings concerning a person to affect his/her work. If a nurse feels that she can not continue a professional relationship on ethical lines she should take her superiors into confidence and discuss the matter with them to find out ways in which the nurse's responsibilities can be ethically handled. If a situation is getting worse and the nurse feels that the quality of healthcare being provided is suffering from conflicts of interest then she should take the necessary steps to get away from the situation depending on the guidelines of the workplace (ANA, 2001).

Moral objections

The code of ethics accepts that nurses are morally autonomous individuals and do not have to let go of their morals while they are performing their duties as medical practitioners. In fact, the code of ethics suggests that morals should come into play at work since they help in giving nurses the courage to raise objections when institutes or health service providers go against the values and ethics of the nursing profession. Nurses are permitted to raise moral objections to certain situations and can become conscientious objectors if the situation demands them to be so (ANA, 2001).

There can be situations where the nurse has a moral objection to performing certain duties or in following certain orders, but the duties or orders are inline with acceptable medical practices and ethics. In such cases, a nurse should try and find alternative methods of providing care to the patient of which the easiest method is to find another coworker who has no objection to the care giving methods being used (ANA, 2001). This permission from the code of ethics is very beneficial for the nurse who has moral objections because he can use this to prevent the creation of any situation that may cause him to lose focus of the primary duties in nursing.

A moral objection is an excellent tool since it allows nurses to be a part of the healthcare decision making process by which services are provided to patients. The code of ethics accepts that nurses may operate at various levels within a health care facility, an educational institute or even an administrative body and that they should not ignore their personal character as they work in these positions (ANA, 2001). This gives all nurses the right to present moral objections, and it places them in a very powerful position when anyone asks if there are any objectors to the acts which another person is about to perform.

As with most situations where power is given to an individual, responsibility also comes into play with the given power. For example, a nurse who makes a conscientious objection is not automatically protected from official or unofficial penalties imposed by the workplace. Additionally, the decision to raise a moral objection must be carefully deliberated because an explanation could be asked for. A nurse should take the time to consider the objections and bring the objection to the table before the procedure starts whenever possible so that alternative arrangements can be made. In fact, even with moral objections a nurse is not ethically permitted to withdraw her assistance until the safety of the patient and alternative nursing care can be arranged (ANA, 2001).