1. Schroeter, Kathryn PhD, RN, CNOR

Article Content

The ethical underpinnings of the duty to provide care stem from the principles of beneficence (to do good) and nonmaleficence (to do no harm). These principles of bioethics recognize and define the moral obligation on the part of nurses to further the welfare, health, and well-being of their patients. The principle of beneficence, in particular, is understood and generally accepted by healthcare professionals and the public to be a foundational principle of the patient-provider relationship.1


The duty to care as an ethical component of the nurse-patient relationship can be inferred from the second provision of the American Nurses Association (ANA) Code of Ethics that notes that the nurse's primary commitment is to the patient.2 Since nursing care is what we as nurses provide, it becomes an ethical obligation, or duty, to provide care for those patients encountered in our practice. In addition, in recent years we have heard much about "care for the caregiver" in articles and seminars with the implication that if nurses don't take care of themselves, how will they be able to care for others? The fifth provision in the ANA Code for Ethics also states that the nurse owes the same duty to self as to others.2


So, it seems that nurses have an ethical obligation not only to care for others but also to care for themselves. This conflict of obligation especially comes into focus during times of disaster when nurses are put in the position to provide care to critically ill or wounded patients for extended periods of time. During these times of pandemics or natural catastrophes, nurses and other healthcare providers must decide how much care they can provide to others while also taking care of themselves. It may be that during times of disaster, our ethical codes serve to guide our professional conduct even more so, functioning as norms of standards that are recognizable and enforceable by law and acting as the foundation of legal obligations and decisions.1


In our current system of healthcare, a strong assertion exists for a social contract between the nurse and society. The public expects that nurses and other healthcare providers will respond to their needs in an infectious disease emergency or in other types of disaster resulting in mass injury or illness. Society, as such, sanctions professions to be self-regulating on the understanding that such a response would occur. But are these public expectations realistic in light of terrorism and natural disasters that may result in huge mass casualties? In this time when healthcare and technology are evolving at a rapid pace, it may be even more imperative to ensure that codes of ethics remain current, realistic, and concordant with public expectations and professional practice environments.


Although self-care and self-protection, as well as the care and protection of friends and family members, are acknowledged in some state or hospital/institutional devised disaster plans for preparedness, we are all aware that the expertise of nurses, physicians, and other healthcare providers is an integral component of the response to a pandemic or disaster. What other segment of society can be realistically and legitimately expected to fulfill this role and assume this level of risk? In light of this level of responsibility, what level of risk are you ready to assume?


You have, most likely, seen trauma nurses and physicians become involved in very high-risk care activities just by virtue of their choice of specialty profession. It is also reasonable to assume that these healthcare providers were aware of the greater than average risks posed by their choice of profession. Does this awareness mean that they forfeit their duties to themselves?


We know that hospitals and institutions also have obligations to provide safe working environments. However, during times of disaster, resources such as gloves, gowns, etc may become scarce. It is during these times that healthcare providers often volunteer to take on even more risk. Should they be able to refuse care in situations that would affect their families or friends? How should each nurse evaluate and what information could or should guide an individual nurse in such situations? Perhaps, we will find that our code of ethics will need to include more specifics on disaster issues so that nurses would feel more willing and comfortable in providing care in uncertain and risky conditions.3


Nurses do not argue that they have a commitment to the nursing profession and to their patients. They know that being a member of such a profession brings with it the respect and trust of the public.4 However, each nurse must know what line he or she will, or will not, cross when it comes to maintaining professional integrity. These concerns should be discussed before times of disaster. That is why so much focus has been on disaster preparedness and planning. Hospitals, institutions, managers, administrators, and healthcare providers need to understand what is expected of them during times of disaster and whether or not they can commit to providing any level of care to their charges when such adverse events occur.


Nurses have a duty to uphold the standards of their profession. As such, they have a commitment to help regulate nursing to protect this public right to quality nursing services while also protecting their own right to self-preservation and self-care. Nurses need to be proactive to address such issues. Trauma nurses are in such positions as to drive decisions regarding the conflict between a nurse's duty to care versus duty to self. Involvement in disaster planning and preparedness committees, councils, and legislation is just one way by which trauma nurses add to this growing knowledge base. Education, both for the professional healthcare provider and the public, is needed to clarify realistic expectations of all involved. As individuals, trauma nurses need to reflect on their own values and integrity to determine what actions they will consider to be morally appropriate for themselves during times of disaster.




1. Ruderman C, Tracy CS, Bensimon CM, et al. On pandemics and the duty to care: whose duty? Who cares? BMC Med Ethics. 2006;7:5. [Context Link]


2. American Nurses Association. Code of Ethics for Nurses With Interpretive Statements. Washington, DC: American Nurses Publishing; 2001. [Context Link]


3. Thompson AK, Faith K, Gibson JL, Upshur REG. Pandemic influenza preparedness: an ethical framework to guide decision-making. BMC Med Ethics. 2006;7:12. [Context Link]


4. Jones J. Lobbyists debut at bottom of honest and ethics list. Published 2007. Accessed December 29, 2007. [Context Link]