|The Role of the American Nurses Association Code in Ethical Decision Making
Ethical decision making is complex and difficult. For this reason, many professions compose ethical codes to aid their practitioners, to aid those in the profession in dealing with perplexing situations that inevitably arise. The American Nurses Association (ANA) Code of Ethics is of course one such code. It outlines the important general values, duties, and responsibilities that flow from the specific role of being a nurse. The relationship of the individual practitioner to the code, however, is an aspect of professional moral life that requires interpretation and may not always be well understood. A historical and theoretical analysis of the ANA Code can provide for an understanding as to how it is to be used not as a substitute for moral thinking but as an aid to moral thinking.
The importance of ethical education for nurses cannot be underestimated, although it is often undervalued and underemphasized. The commitment to ethics in nursing education is at best uneven across programs.1 Some programs require a specific course (or more) in ethics, some claim that an ethical “thread” runs through their courses in general, while some may simply refer students to the American Nurses Association (ANA) Code of Ethics (herein referred to as “the ANA Code” or simply “the Code”) to be read on their own.1 The study of ethics for nurses is important for the nature of the profession, which may often place nurses in morally difficult situations. Also, the distress that may arise from these difficult situations may lead to burnout. A study of ethical theory and cases can provide valuable tools for dealing with these situations and help avoid distress and burnout. The ANA Code is another important tool for such education. Yet, it is often not taught (when taught at all) in a way that would engender the proper esteem it deserves and a fruitful understanding of its meaning, role, and application.1
The most obvious, though not sole, purpose for professional codes of ethics like the ANA Code 2 is to aid in ethical decision making. A profession such as nursing, which intends to serve the good of others with a direct impact on the health and lives of others, is one in which difficult moral problems will arise and, thus, for which a complex ethical outlook is needed. Nurses, on both individual and collective levels, will have to make difficult decisions due to the nature of their profession and practice. Some of these decisions may be important but organizational in nature, whereas others may actually involve dilemmas that impinge on life or death decision making. The ANA Code of Ethics is intended as an aid to these difficult decisions. The danger, though, with any such “aid” is that it may be applied in an unthinking manner as simply a set of preexisting rules.3 Thus, individual practitioners must come to an understanding of the proper relationship between practitioner and Code. Each individual practitioner needs to recognize his or her own moral authority in active collaboration with the writers of the Code; Otherwise, the nurse's subjectivity and autonomy will be compromised. Little will be learned from difficult experience, and complex moral situations will never be fully understood by the moral agent (the nurse).4 A historical and theoretical analysis of ethical codes, in general, and the ANA Code, in particular, will hopefully help define the limitations of the individual decision maker, the limitations of a code of ethics, and the proper relationship one should have toward the Code.
PURPOSE(S) OF THE CODE
The purposes of a professional code of ethics are manifold and often subtle. The ANA defines 3 explicit purposes for the nursing code, but many implicit purposes of this code and of professional codes in general can also be identified. The ANA's expressed purposes of the Code are to be “a succinct statement of the ethical obligations and duties” of every nurse, to be “the profession's nonnegotiable ethical standards,” and to be “an expression of nursing's own understanding of its commitment.”2(p5) All 3 of these expressed purposes are clearly normative and prescriptive. The first indicates that the Code provides moral rules to help guide behavior. The second indicates that the Code applies across the spectrum of nursing roles: patient care, research, and education. The third indicates that the Code recognizes that nurses' obligations place them in a moral relationship to society.
At the same time, codes of ethics in general and the ANA Code specifically can be said to have other important but more implicit purposes. A code of ethics is also an expression of professionalism.5 Having a code of ethics communicates to those in and out of the profession the heightened value and importance of the practices of the profession, that the profession in question performs an important social function important enough to require an expression of professional and moral standards. When standards and obligations are not met, a code of ethics also provides for standards for regulation and enforcement of proper behavior, often in the form of penalties regarding licensure and even legally defining criteria of negligence and professional standards. Another implied purpose is to help develop a group identity.4(p119) A code of ethics, in collecting and codifying the central values of a profession, coalesces what it means to be a member of that profession. In other words, the Code itself helps in a formal manner to define what it means to be a nurse, instilling a more coherent, comprehensive professional identity.
In examining the code of ethics for counselors and psychotherapists, Pope and Vasquez assert that the purpose of this code of ethics is to “prompt, guide, and inform our ethical consideration.”6(p75) This purpose sounds similar to the general purpose of ethical decision making but is distinctive from that in suggesting less dependence on a preexisting set of rules and emphasizing more individual deliberation. The standards of the psychotherapeutic code of ethics, write Pope and Vasquez, “are not a substitute for an active, deliberative, and creative approach to fulfilling … ethical responsibilities.”6(p75) Although Pope and Vasquez are writing specifically about the psychotherapeutic code of ethics, their prescriptive claims can and should apply to other codes of ethics, including the ANA Code.6 Indeed, many claims within the ANA's interpretive statements of the Code explicitly support this more thoughtful, nuanced, individually responsible purpose and interpretation, which a closer analysis will reveal.
HISTORY OF THE ANA CODE
Baker 3 identifies 3 stages through which professional codes of ethics evolve, and through which one can also see the evolution of the ANA Code. The first stage is traditionalism, in which “conduct is regulated by traditions of practice supplemented, perhaps, by disparate formal or semi-formal rules.”3(p33) In nursing, this first stage is represented in the person and spirit of Florence Nightingale. When Nightingale entered nursing, there were no formal ethical standards, but she embodied and advocated for the need of high ethical standards herself.4 The second stage Baker calls formalization.3 In this stage, “some organization, person, or persons amalgamates earlier traditions, precepts, practices, and rules, attempting to construct a coherent assemblage out of them, and, in the process, attempts to rationalize and justify them, and the field more generally, often emphasizing ideals of service to others and dedication to some public good.”3(p33) In nursing, this stage can be seen in the creation of the Nightingale Pledge by Lystra Gretter in 1893. Gretter, in the pledge, attempted to coalesce and formalize the traditionally accepted values and duties that had informally evolved through the history of nursing, as well as more specifically through ethical ideals expressed and practiced by Nightingale herself. This pledge became a “swearing in” oath for nurses similar to the Hippocratic Oath of physicians.4(p118) The obligations formalized in this pledge included those of purely personal morality (“pass my life in purity,” “abstain from whatever is deleterious and mischievous”) as well as professional obligations (not to administer harmful drugs, confidentiality, to aid physicians).4(p118) At this stage, we have a more formalized, coherent statement of ethical ideals, values, and duties but not a statement with explicit and formal profession-wide acceptance and validation.
The third stage is that of professionalization. At this stage, “some organization adopts a formal code of ethics and invests its authority in its promulgation, interpretation, adjudication, revision, and in some measure of direct or indirect enforcement.”3(p33) In nursing, this third stage evolved throughout the 20th century. In 1926, a Suggested Code was provisionally but not formally adopted.2(p27) In 1940, a Tentative Code was published in the American Journal of Nursing but not formally adopted.2(p27) In 1950, the Tentative Code was revised and renamed The Code for Professional Nurses and unanimously accepted by the ANA House of Delegates.2(p27) This code was then further revised as the Code for Nurses With Interpretive Statements in 1976, which was further revised in 1985 and 2001 for the Code we have today.2 This final stage provides both formalization of standards and the imprimatur of the acceptance of a professional organization, bringing with it formal methods of revision, enforcement, and even penalty for violative behavior.
ANALYSIS OF THE CODE
Professional codes of ethics are typically conceived as deontological systems by those who create them and those who subject themselves to a code.4 That is, the codes are seen as composites of strong, if not inviolable, rules. As with any deontological system, situations involving conflicting rules are a potential problem, requiring some resolution process. Secondarily, codes of ethics are often also seen as part of a social contract between individual practitioners and the profession as a whole, concept, or organization. The benefit or consideration for the profession from this aspect of the social contract is that by having a code of ethics as part of the “agreement,” the profession is stronger as a profession.4 Indeed, in the case of nursing, the Code may contribute to nursing being perceived as one of the most trusted professions. On the side of the individual practitioner, the benefits include having a code to which to refer in difficult situations as well as having a published ethical standard of practice, which may provide an ethical and even legal defense against charges of malfeasance.
This social contract view also provides an understanding of the authority held by the Code. Or, as noted earlier, the Code itself has no authority but represents or is representative of authority. Firstly, the Code represents the authority grounded in the considered judgment and deliberation of the committees that composed and revised the various versions of the Code. From the assumption of the experience and clear reasoning of the members of the various committees (including the Code of Ethics Project Task Force) flows an assumption of authority. Furthermore, as in the political theory of contractarianism, authority is borne from tacit or implied assent to the rules by the constituent parties of the contract.7 Thus, nurses, in having earned a nursing degree and living as practicing nurses, tacitly agree to and confer authority upon the Code. Thus, returning to the deontological view of the Code, the rules of which the Code is composed should not be seen as in any way arbitrary or arrived at in a frivolous manner. These rules are not merely chosen and dictated. They flow from the nature of nursing, from broader considerations of medical and healthcare ethics, and from broader considerations of ethics in general. These are rules determined and deduced by the considered deliberation and judgment of the architects of the Code.
Most codes of ethics have little to say regarding character and virtue, as such moral values are more difficult to “codify” than rules and principles of behavior. The ANA Code is arguably unique in its relative emphasis on virtue and character, most especially the virtue of compassion. Most ethicists today recognize the importance of virtue and character in concert with the recognition of rules and principles in order to achieve a more complete and fulfilling moral life and in order to more sincerely and authentically discharge one's moral duties.7 Even in the ANA Code, the primary intended interpretation is likely to have been deontological and contractarian, but the importance of character and virtue is not ignored either.
Structure and content
The ANA Code is composed of 9 provisions or general moral principles. The ANA itself divides these 9 principles into 3 categories. The first 3 are those that “describe the most fundamental values and commitments of the nurse.”2(p6) It would, of course, make sense to place the most fundamental values and commitments first, giving them pride of place and heightened importance. These most fundamental values and commitments include compassion and respect for the dignity of every individual, the primacy of obligations to the patient, and being a patient advocate. The first provision, regarding compassion and respect, refers to “individuals” and thus is not limited to patients but would extend to colleagues, patient family, and any other individual encountered in professional practice. However, the order of the subprovisions or interpretive statements as well as the second and third provisions expressing the ethical primacy of the patient clearly indicates the primary application of the principle. The second 3 principles “address boundaries of duty and loyalty.”2(p6) The fourth provision asserts individual ethical responsibility on the part of the nurse. The fifth requires personal integrity and personal and professional growth. The sixth mandates improvement of working environment. The final 3 “address aspects of duties beyond individual patient encounters”2(p6) and include duties to advance the profession, “promoting community, national, and international … health needs”2(p23) and collective responsibilities to integrity of the profession and social reform.
Although not explicitly noted in the Code, the division and categorization of the provisions suggest a hierarchy in which the duties outlined in the first 3 provisions take precedence. The middle 3 assert important duties that can be viewed as secondary to the primacy of duties to patients outlined in the first 3 provisions. The final 3 assert duties that may indirectly affect individual patients but are clearly aimed somewhere other than the individual patient, toward the profession as a whole and toward the larger society.
A different structural analysis may provide further insight. The obligations contained within the Code can be divided into 4 categories. First are direct obligations to the health and well-being of patients: These include the duties to promote, advocate for, and strive to protect the health and safety of patients and the duties to prevent illness and alleviate suffering. Second are obligations to patients as persons: These duties include compassion and respect for the dignity, worth and uniqueness of every individual, and the promotion, advocacy, and protection of the rights of patients. These duties could also be seen as indirect obligations to the health and well-being of patients. Fulfilling these duties could benefit health and well-being, but that is not their primary focus or purpose. Similarly, neglecting these duties could bring harm to the patients. Third are obligations beyond the patient: “Nursing care,” states the ANA Code, “extends supportive care to the family and significant others.”2(p7) The duties of compassion and respect are also extended to colleagues and “all individual with whom the nurse interacts.”2(p9) The Code further indicates obligations to provide care to groups and communities and to promote “the health, welfare, and safety of all people.”2(p23) And fourth are obligations to self: The ANA Code is one of the few professional codes of ethics that make explicit reference and gives such weight to these obligations. A nurse is not to lose himself or herself in the duty to care for others. These duties include duties to care for a nurse's own health, rights, and moral integrity. Section 5.3 outlines a nurse's ethical duty to express a “moral point-of-view” and to attempt to integrate “personal and professional identities.”2(p19) Section 5.4 further indicates a duty for nurses “to remain consistent with both their personal and professional values and to accept compromise only to the degree that it remains an integrity-preserving compromise.”2(p19)
Again, no hierarchy among these duties is explicitly stated. Some prioritization, however, can be inferred. The Code stresses duties to the patient. This would mean that obligations in the first 2 categories would have at least prima facie priority. A full understanding of nursing care, the nurse's role, and the duties that follow from these, though, would include the obligations of the third category. And without obligations of the fourth category, the nurse as a person would be swallowed up by her or his role as a nurse.
Because of the uncertainty of prioritization of the various types of obligations, moral conflict, even dilemmas, will inevitably arise. Duties to self and others commonly conflict. Duties to the patient and family may even conflict. There may even be conflict between obligations to a patient's health and well-being and obligations to protect a patient's rights. Conflicts may even arise internal to the categorizations above because of the uncertain nature of rights, the uncertain nature of medicine, conflicting needs and desires of a patient's family or the community, and the difficulty of integrating professional and personal identities.
LIMITS OF THE CODE
Any code of ethics is subject to certain necessary limitations. The most basic of these is human fallibility. As much presumptive authority as we might give the considered judgment of those who write and revise these codes; we cannot presume infallibility on their part. Humans, technically and morally, are fallible creatures. As such, we cannot presume any statement on morality—particularly one as complex as a professional code of ethics—to be without flaw, complete, and comprehensive.
Even setting aside human fallibility, no code can reliably foresee changes in technology and environmental and organizational structures that might bring new ethical challenges. In the 20th century, technological advancement in reproduction, therapeutic research, life support, and organ transplantation brought unforeseen challenges to medical and healthcare ethics. Environmental and organizational changes can also present new ethical challenges. The ANA Code itself suggests this: “Situations created by changes in health care financing and delivery systems, such as incentive systems to decrease spending, pose new possibilities of conflict between economic self-interest and professional integrity.”2(p10) That the Code would note these possibilities is a strength of it. The fact that these are “new possibilities” may mean the Code as it stands may not be entirely suited for navigating the conflicts engendered by these new possibilities.
Finally, and perhaps most simply, any code of ethics is limited by the infinite variety of concrete, particular situations in which any individual nurse is likely to find himself or herself. Codes of ethics are of necessity articulated in general terms, laying out fundamental values and broad principles of action. The recognition of these values and the application of these principles leave much room for interpretation for the individual practitioner in real and specific situations. There is no way of course any code could foresee all moral conflicts and situations and particularize rules to the point of abrogating interpretation and active, mindful application of the Code's standards by the individual practitioner. Indeed, if a code did or could, this would not be a good thing.
APPLYING THE CODE IN ETHICAL DECISION MAKING
As Baker notes, “Opponents of codes often tend to see them as fixed and unchanging.”3(p34) Baker quickly dismisses this criticism, noting that writers of codes “set out, not so much to invent or dictate standards, but to discover and aggregate standards accepted or formulated in the field.”3(p34) These claims can easily be seen supported by much in the preceding analysis. Standards set out in codes of ethics are not invented or dictated but discovered and aggregated from the tradition of practice and given a clear and formal voice through codification. The “discovered,” rather than “invented,” nature of the standards in these codes is an element that needs to be particularly emphasized to student nurses and nurses in general. Such emphasis would mitigate a real problem with such codes. The problem is not that they are, according to Baker, some believe, “fixed and unchanging, engraved from on high in stone tablets by those who presume the prerogative of dictating proper conduct to others,”3(p34) but that many who subject themselves to codes of ethics may perceive them in this manner.
The nature and claims of the ANA Code themselves militate against any such inflexible monolithic interpretation. The fact that the Code has been revised several times seems to be a sign not only of its need to adjust to the changing technological, cultural, and healthcare environment, but also of a recognition by its architects and curators of its fundamental fallibility. The Code opens with a description of the ethical tradition of nursing as “self-reflective, enduring, and distinctive.”2(p5) As “enduring,” nursing ethics expresses, emphasizes, and reemphasizes certain core values and standards over time, and even over changes in culture and healthcare environments. As “distinctive,” nursing ethics expresses an ethical viewpoint that, while continuous with the larger moral culture in which nursing operates, is clear and distinctive, as following from the particular needs and nature of nursing and healthcare. Most importantly, in this context, as “self-reflective,” nursing ethics constantly questions and challenges its own standards and values. It looks at itself as a means of best defending against the necessary and inherent fallibility of any human ethical system. And, by implication, the individual practitioner should be similarly self-reflective, to enhance practitioner autonomy and ensure the best decision making.
The Code also describes itself as a “dynamic document.”2(p6) This statement seems to be an explicit expression of the Code's fallibility and openness to change and revision. And such a claim is then reinforced by the instances of revision to which the Code has been submitted. Furthermore, the Code describes itself as providing “a framework for nurses to use in ethical analysis and decision-making.”2(p6) As a “framework,” the Code is clearly not intended to be comprehensive in the sense of foreseeing all particularized moral situations.2(p6) The reference to “analysis and decision-making” more explicitly asserts an active, mindful role for the nurse in applying the Code.
Again and again, within both the 9 main provisions and the qualifying interpretive statements that follow each, the Code asserts and emphasizes the individual practitioner's own deliberation and judgment in dealing with moral problems and applying the standards of the Code, thereby also implying the limitations outlined above. This emphasis on individual decision making is most clearly asserted in Provision 4, which states, “The nurse is responsible and accountable for individual nursing practice….”2(p16) This assertion of responsibility and accountability implies, of course, the individual practitioner's own use of judgment, as one can be responsible only for his or her own autonomous decisions. In the more detailed interpretive statements, the Code further recognizes situations in which the nurse must weigh “the right to self-determination” against “the rights, health and welfare of others”2(p9); individual examination of conflicts between “personal and professional values, the values and interests of others who are responsible for patient care and health care decision”2(p10); and the exercising of “judgment in accepting responsibilities, seeking consultation, and assigning activities to others who carry out nursing care.”2(p16) The interpretive statements further acknowledge possible changes to the scope of nursing practice, requiring the exercise of individual judgment. Provision 4 further heightens the responsibility of nurses' judgments as independent of “health care organizations' policies or providers' directives.”2(p16) Provision 5's emphasis on maintaining personal integrity to integrate personal and professional identities, and “accept compromise only to the degree that it remains an integrity-preserving compromise,”2(p19) further implies a fundamental need for individual deliberation and judgment, as only the individual can truly assess her or his personal morality and integrate it with professional identity and morality. Provision 5 further allows for conscientious objection, which would require a process of personal moral deliberation and even mandates leaving the employment of “facilities that routinely violate patient rights or require nurses to … compromise standards of practice or personal morality.”2(pp20–21)
It is clear from the statements within the ANA Code that the ANA recognizes the fallibility of its code, the particularities of moral problems; the changes in technology, culture, and the healthcare environment; and the challenge of the integration of personal and professional identities. Thus, the Code itself mandates a mindful, interpretive application of its standards and the use of personal judgment. Also, as stated clearly in the ANA Code, this emphasis on personal judgment—especially as “irrespective of health care organizations' policies or providers' directives”2(rm p16)—means that responsibility and accountability for decisions rest on the individual practitioner as autonomous agent. The Code does not make decisions, and neither the Code nor the architects of the Code are responsible for decisions. Decisions though are made in concert with the considered judgment inherent in the Code itself. “The ethical decision is made by the individual practitioner,” note Peterson and Potter, “but is made in the context of the personal/professional/society interaction.”4(p118) Peterson and Potter further assert that the “final arbiter in a moral decision” is not the “individual conscience” but the “group with which the individual practitioner identifies.”4(p118) Such professional, ethical decisions are a form of collaboration then between the individual nurse and the ethical standards of practice as outlined in the ANA Code in which nursing as a profession, the ANA, or the House of Delegates of the ANA is the final arbiter (which specifically is a matter of further interpretation), but the individual nurse is the responsible, accountable party.
So much emphasis on personal decision making and personal responsibility, along with the many limitations of the Code, seems to raise, at least theoretically, a difficult and problematic issue: decisions and actions contrary to the values and standards of the Code. One can act contrary to a relevant code of ethics in 3 ways: negligence, willful disobedience, and moral resistance. Negligence simply means acting either without reasonably expected regard or knowledge of the Code, or a fundamental lack of reflection in one's actions and decisions. Willful disobedience refers to acting with indicative and moral knowledge that one's decisions are contrary to the Code. These first 2 types of contrary acts are clearly immoral acts for which the agent is culpable.
The third type presents a special complexity. Moral resistance—possibly a form of conscientious objection, as defined by this author—is similar to willful disobedience in that one acts with full knowledge that the Code is being violated, but with moral resistance one believes (either rightly or wrongly) that one is morally justified in such violations. The moral justification would be based on the agent's personal deliberation and perhaps reference to moral considerations and principles beyond or broader than those included in the Code. The possibility of this type of act is itself implied in the Code when it refers to moral decisions that—though presumably consistent with the ANA Code—may not be consistent with “health care organizations' policies or providers' directives.”2(rm p16) If it is possible to morally act contrary to the policies of a healthcare organization or the directive of a healthcare provider, then it is also possible to morally act contrary to a code of ethics. This possibility was qualified as “theoretical” because, given the deep consideration and multiple revisions that went into the ANA Code, such justifiable moral resistance seems unlikely. Yet, given that the ANA Code is a “dynamic document”2(p6) open to further consideration and revision, such a possibility is still there. As an historical example, consider that until the late 1970s, hospitals had a hierarchical structure that placed nurses at the bottom.8 Nurses were expected to give unquestioning obedience to the hospital and to physicians. A direct and explicit duty to patients was not recognized as it is today. In addition, the ANA Code of the time reflected this view of nurses and the nurse's role. Yet, if during this period of time, a nurse were to disregard or refuse the orders of a physician or hospital administration because of the nurse's well-established belief that such orders are contrary to the good of the patient, one could see such actions as morally justifiable. Such actions may not be consistent with professional standards and such behavior might invite penalty, but such actions might be the morally correct path.
The complication here comes with the question of culpability. If the agent is morally correct in acting against the Code, it would seem morally incorrect to hold the agent culpable for such “malfeasance.” The Code asserts that it is “nonnegotiable”2(p6,26) and can be revised only “by formal process of the House of Delegates of the ANA.”2(p6) Thus, although the ANA recognizes the Code's fallibility, leaving it open to revision, such revision, for purposes of moral stability and forthrightness, is not the responsibility of individual practitioners but of a formal, specially empowered committee. It seems then that an agent who justifiably resists the imperatives of the Code would be considered morally culpable and would expect penalty or censure of some sort. From a broader moral perspective, though, it remains unclear whether such reaction is morally correct. With the possibility of moral censure or penalty in mind then, it would seem an act of moral courage to justifiably resist the Code, just as it would be when one resists improper policies of his or her place of employment, in which case one would also expect to face penalty even though he or she is “right.” It should be further emphasized that such justifiable moral resistance to a code such as this seems very unlikely.
According to Wilson,9 a primary reason for nurses leaving the profession is difficulty in applying ethical rules. More recently, Biton and Tabak reinforce this claim, stating that an “inability to implement the ethical code at work forces the nurse to compromise on a professional level, resulting in burnout.”5(p141) Furthermore, claim Biton and Tabak, “implementation of the ethical code … is correlated with professionalism and to raising nurses' autonomy level, enabling them to implement their commitment to the ethical code on a higher level.”5(p142) Being able to properly and effectively apply the Code and perform one's professional functions in a moral manner and maintaining personal integrity obviously has basic practical purposes as well as more idealistic or academic ethical purposes. Given this correlation between ethical judgment and job satisfaction, the nature of ethical codes in general and the ANA Code in particular, as well as the emphasis in the ANA Code on individual deliberation and judgment in collaboration with the Code, the ethical education of nurses should include a pronounced emphasis on individual ethical deliberation and judgment. This pronounced emphasis should include not only analyses of cases and instruction in ethical theory but also an analysis of the Code as the product of considered judgment, as the process of a discovery rather than invention of values and standards. An understanding of the thought, deliberation, and redeliberation of the Code (through revisions) will support and encourage the nurse's own ethical judgment, thereby encouraging and increasing autonomy and fostering an active, mindful, participatory relationship with the code of ethics.
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KEY WORDS: ethics; ethical code; nursing; nursing philosophy