When care collides with nurses’ morals, ethics
Last winter, two high-profile — and very tragic — cases pitted family members against hospital administrations and stirred debates nationwide about brain death, policies and laws, and ethics. No matter where they practice, nurses may have wondered what they would do if they found themselves in similar circumstances — whether they could object to providing patient care. The answer is a qualified “yes.”
First, the two cases
According to published reports, Jahi McMath, 13, was admitted into a California children’s hospital for surgical procedures to address sleep apnea. Following surgery, she developed a complication, went into cardiac arrest, and was declared brain dead by two hospital-associated physicians and ultimately a court-ordered physician. Her family fought to have her remain on a ventilator until she could be transferred to an undisclosed facility where she could be given additional “life-sustaining” measures.
Marlise Munoz was 14 weeks pregnant when she was found unconscious at home. She was declared brain dead and carrying a nonviable fetus; her family wanted her taken off life support, noting her wishes, the media reported. But this time, the hospital where she was admitted objected — citing a Texas law it believed required them to keep her on life support until her fetus could be delivered. Again, a legal battle ensued. A judge ultimately ruled that the hospital was misapplying the law, and the hospital removed her from life support.
Members of the American Nurses Association (ANA) Ethics and Human Rights Advisory Board were not aware whether RNs objected to providing care in these specific cases. However, nurse ethicists did find it crucial to ensure that all RNs understand that they can conscientiously object to participating in interventions if certain criteria are met.
Confronting difficult decisions
Nurse ethicist Anita Catlin, DNSc, FNP, FAAN, followed the Munoz case in the national press.
“Nurses have a right to conscientiously object to participate in technologically supported treatment of a brain-dead person,” shared Catlin, a member of ANA’s ethics advisory board. “Additionally, when a woman and her surrogate have made their wishes known, it is unethical to go against these wishes as stated in ANA’s Code of Ethics for Nurses with Interpretive Statements.
“If members of the nursing staff wished to be excused from participating in this patient’s care for anything other than palliative care and comfort measures, they have every right to do so.”
When it comes to nursing practice, there are two broad categories in which RNs can conscientiously object to participate — based on provisions addressed in the Code of Ethics, according to Marsha Fowler, PhD, MS, MDiv, RN, FAAN, a member of the ANA’s professional issues panel steering committee, which has been leading a revision of the Code.
Nurses can refuse to participate in all instances of an intervention — such as an abortion or sexual reassignment surgery — based on religious or moral grounds, said Fowler, an ANA\California member. RNs who hold these strong beliefs should make their objections to participate in these types of interventions or procedures known at the time of hiring, Fowler said.
“If that’s not possible for some reason, the nurse should make her or his objection as timely as possible so the nurse manager can find a replacement,” she said.
Vicki Lachman, PhD, MBE, APRN, FAAN, added that for nurses to ethically object to participating in an intervention, that intervention “must challenge their moral integrity — and not be based on false motivation. It really has to violate a deeply held conviction of what’s right or wrong. A nurse might believe that the sanctity of life trumps all.”
The Code does not allow nurses to refuse care based on prejudice, discrimination or dislike. For example, they can’t refuse to take care of someone because the patient abuses alcohol or because the patient is homosexual, according to Lachman, chair of ANA’s ethics advisory board.
To decrease the chances of having to object on moral or religious grounds, nurses ideally should practice in settings where they are less likely to be confronted with interventions — such as abortions, cardiac transplants or palliative sedation — that conflict with their beliefs, Lachman said.
The other broad category in which nurses can conscientiously object involves a specific intervention with a specific patient, Fowler said. A common example of this ethically sound objection is when a nurse is asked to participate in an intervention that goes against a patient’s autonomy and expressed desires, as in the patient’s not wanting a blood transfusion, antibiotics or other lifesaving measures.
Given the fast pace of technology and other advances, nurses may increasingly find themselves in ethically challenging situations, Lachman noted.
Additionally, many sensitive cases that might have been kept private in decades past are now being played out in the media, according to Fowler.
To make a conscientious objection, Fowler said nurses should follow the lines of authority and the structures that are in place in their facilities. They also can contact their organization’s ethics committee or patient ombudsman.
And they must be aware of an obligation not to abandon a patient.
“Once a nurse begins treating a patient, she or he is legally bound to care for that patient until another nurse is available to assume responsibility for the patient,” Lachman said.
And although it may take courage to conscientiously object — particularly given some workplace cultures — not doing so can have dire consequences for the individual nurse and for the nursing profession.
“Most of the time, nurses just remain silent and do not make their objections known. They also worry that their decision will place a burden on colleagues by giving them more work,” Lachman said. “If nurses cannot move away from these situations, it becomes intolerable. They experience moral distress, emotional and physical fatigue, and burnout. Therefore, organizations must provide nurses with the staffing necessary to maintain their moral integrity, and nurses need to participate only in patient care that is not morally compromising. ”
Fowler added, “Nurses need to accommodate and support colleagues who conscientiously object and provide an environment that preserves professional integrity.”
— Susan Trossman is the senior reporter for The American Nurse.
To view the current Code of Ethics, visit http://nursingworld.org/codeofethics
The revised Code is expected to be published by early 2015.
For Vicki Lachman’s article, “Conscientious Objection in Nursing: Definition and Criteria for Acceptance”: MedSurg Nursing Journal, May/June issue