Ethics and Legal Issues in Nursing — Comprehensive Notes

Ethics: Definition and Scope

• Ethics is the study of human behavior, focusing on morals, principles, and the rightness or wrongness of actions. It is not the same as law.
• An ethical dilemma arises when there is friction between opposing principles or values; if everyone agreed on a plan about right or wrong, no ethical dilemma would exist.
• Ethical and legal issues are distinct: something can be legal but not ethical, or ethical but not legal (and vice versa).
• Real-world example contrasts: legal to return a Christmas tree to Costco for a refund, but morally questionable for some individuals; or breaking and entering as a legal matter vs. moral judgment.
• Bioethics focuses on life and healthcare decisions, where debates include abortion, end-of-life care, quality of life, and directives. These issues are rarely black-and-white and involve many variables.

Core Ethical Principles

• Golden Rule: treat others as you want to be treated; a foundational fallback when uncertain.
• Autonomy (self-determination): patients have the right to make their own decisions about their care, even if the provider disagrees. Example: a chronically ill patient chooses to live in a trailer without electricity or running water.
• Veracity (truth-telling): always strive to be truthful and transparent with patients; avoid spinning the truth. Historical practice has shifted toward greater transparency.
• Beneficence (doing good): act to promote the patient’s well-being, balancing benefits and burdens. Example: turning a bedridden patient to prevent skin breakdown, even if it causes some discomfort.
• Nonmaleficence (not doing harm): avoid causing harm, whether intentional or unintentional. Consider futile interventions in end-of-life care.
• Fidelity (promise-keeping): keep commitments made to patients (e.g., returning with coffee or giving pain meds on time). Breaks in promises erode trust.
• Justice (fair and equal treatment): treat all patients with the same standard of care, with no favoritism or bias.

Ethical Theories and Concepts

• Deontology: judging right or wrong by the intention behind the action; emphasizes duty and principled action. Example: Good Samaritan laws protect well-intentioned helpers who may inadvertently cause harm.
• Paternalism: when decisions are made for others based on the belief that authority figures know best. Modern health care increasingly emphasizes teamwork and shared decision-making rather than a sole physician as conductor.
• Rights of Consciousness: protections in the workplace for beliefs that may conflict with certain duties (e.g., Jehovah’s Witnesses and blood products). Negotiation with management is often required.
• Values and Cultural Differences: awareness of differing cultural values and practices, including arranged marriages and other customs.
• Utility/Utilitarianism: the greatest good for the greatest number. Example: allocating a $1,000,000 gift to vaccinate many children in a county rather than paying for one patient’s expensive medications for several years.
  • ext{Utilitarian objective} = ext{maximize } igg( ext{sum of benefits across all affected individuals} igg)
• Feminist Ethics: emphasizes who is involved and relational aspects rather than solely the outcome or rules.
• Confidentiality and Accountability: safeguarding patient information (HIPAA) and holding oneself accountable for actions. Confidentiality builds trust; accountability defines responsibility for actions.
• Responsibility vs. Accountability:
  • Responsibility: the duty described in a job role (e.g., monitor vital signs every four hours).
  • Accountability: being answerable for actions (e.g., explaining why a vital sign assessment was not performed).
• Advocacy: nurses advocate for patients, which may require challenging families, physicians, or other professionals when necessary.
• Decision-Making in Ethics: decisions should be rational, systematic, and process-driven; prioritize patient values and preferences; involve collaboration.
• Moral Distress: discord between personal beliefs and professional duties; discuss with instructors or peers to resolve.
• Ethical Decision-Making Process: aim for rational, systematic, and patient-centered reasoning; preserve integrity and ensure every voice is heard.

Ethical Decision Making in Practice

• Always fall back on patient wants and values; prioritize patient-centered care.
• Collaboration is key: multidisciplinary teams (physicians, nurses, social workers, pharmacists, dietitians) work together to determine the best plan of care.
• Ethical acculturation: students and professionals are constantly learning the norms, expectations, and reasoning processes of the nursing profession.
• When in doubt, seek guidance from experienced colleagues or instructors to reduce moral distress and improve decision quality.

Professional Standards and Codes

• ANA Code of Ethics: a formal standard of ethical practice for nurses; used to evaluate alleged ethical violations.
• Ethical acculturation for students: developing ethical reasoning skills through classroom, clinical, and lab experiences.
• Deontology and the Good Samaritan: juristic protection for good-faith actions; healthcare providers must still adhere to a higher standard than the lay public.

Rights, Consent, and Autonomy in Care

• Informed consent: patient education about benefits, alternatives, and consequences of not treating; the patient must be adequately educated and capable of consent.
  • Written consent is part of the process; the nurse often witnesses and ensures that the patient is adequately informed.
  • If a patient cannot consent (e.g., due to impairment), a substitute decision-maker (guardian or power of attorney) is used; advance directives may guide decisions when capacity is lacking.
• Implied consent: consent inferred from patient actions (e.g., a patient who sits in a chair and agrees to radiology).
• Groups who cannot consent:
  • Minors (consent provided by parents/guardians)
  • Unconscious or intoxicated individuals
  • Those with limited mental capacity to understand
• Advanced directives: documents that specify a patient’s preferences for care in the event they cannot express those wishes. Content to be covered in future sessions.

Confidentiality, Privacy, and Professional Boundaries

• Confidentiality and HIPAA: laws and ethical obligations to protect patient information; trust is essential for effective care.
• Invasion of privacy (quasi-intentional tort): discussing patient information without authorization or sharing non-patient-identifying details that allow others to infer the patient.
• Charting and defamation risk: ensure documentation is factual, objective, and quotes are used for patient statements to avoid libel or slander.
• Documentation and communication: real-time, accurate documentation is critical; communication of status changes to the care team is essential.

Safety, Accountability, and the Standard of Care

• Standard of care: what a prudent nurse would do in a given situation; all steps in a medication administration process are critical; there are no “easy outs.”
• Doronda Bot case (Vanderbilt ICU): a nurse accidentally gave a paralytic agent instead of a sedative; led to criminal charges; highlights the high stakes of medication safety and accountability.
• Common sources of torts in health care:
  • Failure to assess and monitor (e.g., vital signs, post-medication monitoring)
  • Failure to prevent aspiration or manage respiratory status
  • Deterioration in ambulatory status or new functional limitations
  • Incorrect use of equipment or failed quality checks
  • Failure to communicate critical information (e.g., lab results that impact imaging or procedures)
  • Inaccurate or incomplete documentation
  • Inadequate discharge instructions or patient education
• Delegation considerations: you can delegate tasks, but the clinical reasoning and accountability remain with the licensed nurse; e.g., medication administration by a non-licensed assistive person must not involve clinical judgment.
• Falls, restraints, IV-related injuries, and related protocols: use least restrictive measures; require physician orders; follow safety protocols.
• Failure to bring questions or orders to the ND: do not assume an order is correct; verify and understand the rationale.
• Discharge education: emphasize understanding; use multimodal teaching approaches to accommodate different literacy levels and learning styles.

Informed Consent in Practice

• Informed consent components: benefits, alternatives, and what happens if treatment is not performed.
• Nurse’s role: ensure the patient has been adequately educated and has had questions answered; document the consent process.
• When consent is invalid or incomplete: contact the physician or surgeon to address questions; ensure consent is obtained before proceeding with invasive procedures.
• Implied vs. explicit consent: explicit consent is written or oral; implied consent is inferred from action (e.g., patient travels to radiology).

Common Ethics and Legal Scenarios to Memorize

• Ethical scenarios often involve balancing autonomy, beneficence, nonmaleficence, fidelity, justice, and veracity.
• Conflicts may arise with family wishes, physician recommendations, or cultural or religious beliefs; advocate for the patient while engaging the care team.
• Moral distress resolution: seek guidance, reflect, and discuss to align actions with patient values and professional standards.

Quick Reference: NC Board of Nursing (Key Duties Regardless of Staffing)

• Protect a client at risk of harming themselves or others.
• Accurate medication administration.
• Implementing a treatment regimen.
• Evaluation of status (response to treatment).
• Documentation (ideally in real time).
• Communication of status changes (to the team and physician).

Quick Reference: Torts and Legal Concepts (Definitions)

• Tort: a violation of a legal duty, resulting in harm or injury to another.
• Intentional tort: deliberate actions intended to cause harm (e.g., assault, battery, false imprisonment).
• Assault: threatening to inflict harm or making a harmful gesture or statement.
• Battery: actual physical contact or administration of a harmful procedure.
• False imprisonment: unjustified restraint of a patient; may involve restraints or keeping a patient in a room against their wishes.
• Invasion of privacy: improper disclosure or discussion of patient information; can be via non-consensual sharing or nosy behavior.
• Defamation: libel (written) or slander (spoken); nurses must document factually and avoid subjective judgments about patients.
• Negligence: failure to meet the standard of care, often by omission or careless action.
• Malpractice: professional negligence; requires a duty, breach, causation, and damages; can occur even if not intentional (e.g., wrong medication, wrong procedure).

Informed Consent and Discharge Planning: Practical Points

• Discharge education should be multimodal (diagrams, videos, handouts) to accommodate literacy levels and learning styles.
• Verify patient understanding; tailor explanations to the patient’s context and language.
• Ensure power of attorney and/or advance directives are in place for patients who lack capacity.
• Always document informed consent and education provided, including patient questions and physician responses when needed.

Next Steps and Tools

• QR code activity on ethics terminology to reinforce understanding of terminology and concepts.

• Values clarification exercise to identify your own biases and how they may affect patient care.

• Prepare to discuss advanced directives in upcoming sessions.

• Equations and notation used in ethical reasoning:

  ext{Utilitarian objective} = ext{maximize } igg( ext{sum of benefits to all affected individuals} igg)

  ext{Optimal allocation} = ext{arg max}_{allocation} igg( ext{total utility} igg)

• Numerical references from the lecture:

  • Medical aid in dying currently legal in $11$ states plus the District of Columbia (DC).
  • Time windows referenced for withdrawal or care dynamics include $24 ext{ to } 72$ hours after last consumption of alcohol for withdrawal risk.

Connections to Other Topics

• These ethics concepts tie into foundational principles used in clinical decision-making, patient autonomy, and the multidisciplinary approach to care.
• Understanding the difference between ethics and law helps anticipate conflicts and navigate moral distress in clinical settings.
• The content builds toward more advanced topics in Advanced Directives and end-of-life care in subsequent lectures.