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Ethical Issues in Critical Care 79

refraining from obstructing their actions unless these are
BOX 5.1 Australian Nursing and Midwifery clearly detrimental to others or themselves. To show lack
Council Code of Ethics for Nurses in of respect for an autonomous agent, or to withhold infor-
Australia, June 2002 61 mation necessary to make a considered judgement, when
there are no compelling reasons to do so, is to repudiate
Value statements that person’s judgements. To deny a competent indivi-
1. Nurses respect individual’s needs, values, culture and vul- dual autonomy is to treat that person paternalistically.
nerability in the provision of nursing care. However, some persons are in need of extensive protec-
2. Nurses accept the rights of individuals to make informed tion, depending on the risk of harm and likely benefit of
choices in relation to their care. protecting them, and in these cases paternalism may be
3. Nurses promote and uphold the provision of quality nursing considered justifiable. 6,7
care for all people. According to the principle of autonomy, critical care
4. Nurses hold in confidence any information obtained in a patients are entitled to be treated as self-determining.
professional capacity, use professional judgement where Where the patient is incompetent, healthcare profession-
there is a need to share information for the therapeutic als ought to act so as to respect the autonomy of the indi-
benefit and safety of a person, and ensure that privacy is vidual as much as possible, for example by attempting to
safeguarded. discover what the patient’s preference would have been in
5. Nurses fulfil the accountability and responsibility inherent the current circumstances. (This requirement will be dis-
in their roles. cussed in detail in the section below on decision making.)
6. Nurses value environmental ethics and a social, economic
and ecologically sustainable environment that promotes Nurses are autonomous moral agents, and at times may
health and wellbeing. adopt a personal moral stance that makes participation
in certain interventions or procedures morally unaccept-
able (see the Conscientious objection section later in this
chapter).

Beneficence and Non-maleficence
BOX 5.2 Nursing Council of New Zealand The principle of beneficence requires that nurses act in
Code of Conduct for Nurses, December ways that promote the wellbeing of another person; this
2004 15 incorporates the two actions of doing no harm, and maxi-
mising possible benefits while minimising possible harms
Principles (non-maleficence). It also encompasses acts of kindness
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1. The nurse complies with legislated requirements. that go beyond obligation. In practice this means that
2. The nurse acts ethically and maintains standards of although the caregiver’s treatment is aimed to ‘do no
practice. harm’, there may be times where to ‘maximise benefits’ for
3. The nurse respects the rights of patients/clients. positive health outcomes it is considered ethically justifi-
4. The nurse justifies public trust and confidence. able that the patient be exposed to a ‘higher risk of harm’
(albeit ‘minimised’ by the caregiver as much as possible).
For example, in the coronary care unit (CCU) a patient
may require a central venous catheter (CVC) to optimise
dilemmas’. Dilemmas are different from problems, fluid and drug therapy, but this is not without its own
because problems have potential solutions. 5 inherent risks (e.g. infection, pneumothorax on inser-
tion). Evidence-based protocols exist for caregivers/nurses
ETHICAL PRINCIPLES for both the safe insertion of a CVC and subsequent care,
Key ethical (moral) principles include autonomy, benefi- so as to minimise possible harms to the patient.
cence, non-maleficence, justice and paternalism. Other
related ethical concepts include integrity, best interests, Justice
informed consent and advance directives. All are appli- Justice may be defined as fair, equitable and appropriate
cable to critical care practice. Some of these principles treatment in light of what is due or owed to an individual.
and how they relate specifically to critical care nursing The fair, equitable and appropriate distribution of health
practice are discussed individually in this chapter. Others care, determined by justified rules or ‘norms’, is termed
are incorporated in broader issues, such as brain death distributive justice. There are various well-regarded theo-
6
and organ donation. ries of justice. In health care, egalitarian theories generally
Autonomy propose that people be provided with an equal distribu-
tion of particular goods or services. However, it is usually
Individuals should be treated as autonomous agents; and recognised that justice does not always require equal
individuals with diminished autonomy are entitled to sharing of all possible social benefits. In situations where
protection. An autonomous person is an individual there is not enough of a resource to be equally distrib-
capable of deliberation and action about personal uted, often guidelines or policies (e.g. ICU admission
goals. To respect autonomy is to give weight to autono- policies) may be developed in order to be as fair and
mous persons’ considered opinions and choices, while equitable as possible.