Bioethics in Nursing Practice
Core Ethical Principles
Nursing practice is fundamentally guided by four essential bioethical principles: autonomy (patient self-determination), beneficence (promotion of well-being), nonmaleficence (avoidance of harm), and justice (fair allocation of resources and protection of vulnerable populations). 1
These principles form the foundation of ethical decision-making in nursing and must be balanced against each other, as they are not absolute and can conflict in clinical situations. 1
The Four Pillars Explained
1. Autonomy (Respect for Patient Self-Determination)
- Requires nurses to inform patients about their diseases, prognoses, and the risks, benefits, and alternatives to tests and treatments. 1
- Respecting patient autonomy is central to the Royal College of Nursing's definition of nursing practice. 2
- Autonomy is not absolute and must be balanced with other ethical principles to enable nurses to practice high-value care in the patient's best interest. 1
- Nurses must recognize that the patient-clinician relationship is inherently unequal due to power differentials and the vulnerability of illness. 1
- Addressing patient autonomy and quality of life are ethical priorities in the majority of ethically difficult nursing situations. 3
2. Beneficence (Acting for Patient Benefit)
- Refers to the nurse's duty to act for the good or benefit of patients. 1
- Requires weighing anticipated benefits and harms of tests and treatments in the context of the patient's prognosis and healthcare-related goals. 1
- The "double effect" principle allows nurses to administer potentially harmful medications or treatments if the intent is good, the harmful effect is not intended, and potential benefits outweigh harms. 1
3. Nonmaleficence (Avoiding Harm)
- Refers to the nurse's duty to prevent or avoid harming patients. 1
- Nurses must avoid futile care, such as nonindicated cardiopulmonary resuscitation or end-of-life treatment when inconsistent with patient goals. 1
- Medicine cannot relieve all human suffering, and attempting to do so can lead to bad medical care. 1
4. Justice (Fairness and Resource Allocation)
- Requires that nurses base testing and treatment recommendations on medical evidence and need, not on patient-specific characteristics such as race or sex. 1
- Involves protection of vulnerable populations including the sick, elderly, children, disabled, poor, and minorities. 1
- Addresses fair allocation of healthcare resources. 1
Application in Clinical Decision-Making
Balancing Competing Principles
- When ethical principles conflict, nurses must engage in systematic analysis rather than defaulting to one principle. 1
- The dialogue must follow culturally sensitive approaches, as culture influences priorities and values. 1
- Nurses who are specific in their ethical analysis and proactive in their action choices achieve better outcomes than those who analyze ethics from a diffuse perspective. 3
Communication and Advance Care Planning
- Nurses should facilitate compassionate communication on disease progression, helping individuals define goals of care and preferences for future medical treatment. 1
- Discussion about prognosis serves as a springboard for difficult conversations, facilitating decision-making while addressing patient preferences and treatment rationales. 1
- Nurses must be therapeutically present ("here and now"), enhance patient dignity, be open to spiritual needs, and assist in the patient's quest for meaning. 1
Addressing Spiritual and Holistic Dimensions
- Spiritual care addresses an essential aspect of humanity and should be integrated into nursing care. 1
- Whole-person care focuses on curing illness while acknowledging the simultaneous process of internal healing—becoming psychologically and spiritually more integrated. 1
- Greater spiritual well-being is associated with lower incidence of depression and better cardiovascular outcomes. 1
Common Ethical Challenges in Nursing
End-of-Life Care Decisions
- Nurses must inform patients with implantable cardiac devices of the option to withdraw device therapies or deactivate device functions, and this should be discussed in advance. 1
- Ethical support for refusing life-sustaining treatment is strong, as death follows naturally from the underlying disease after refusal. 1
- Nurses should remain present, provide compassionate care, and enlist support from interdisciplinary teams when addressing suffering beyond medical scope. 1
Vulnerable Populations
- Special ethical duties apply to the most vulnerable: the sick, elderly, children, disabled, poor, and minorities. 1
- Nurses must be vigilant that vulnerable individuals do not view themselves as unproductive or burdensome. 1
Resource Allocation and Screening
- Screening tests may be nonbeneficial or harmful if the time horizon to benefit exceeds remaining life expectancy, especially as harms increase with age and comorbidity. 1
Critical Nursing Actions for Ethical Practice
Nurses have identified 12 ethics-specific activities, five ways of being, three ways of knowing, and two ways of deliberating when addressing ethical situations. 3
Proactive Approaches
- Stronger and more proactive nursing voices with early ethics interventions contribute valuable improvements to quality of care, especially at end of life. 3
- Evidence-based nursing interventions that promptly identify and address moral conflict benefit patients, families, and the entire healthcare team by mitigating moral distress. 3
Common Pitfalls to Avoid
- In 21% of ethically difficult cases, nurses chose not to pursue concerns beyond providing standard care, leading to significant regret. 3
- Most regrets involved unnecessary pain and suffering, with nurses claiming they did not do enough for the patient. 3
- Nurses must avoid analyzing ethics from only one dimension and instead conduct comprehensive ethical analysis. 3