Page 104 - ACCCN's Critical Care Nursing

Ethical Issues in Critical Care 81

patient and the overall duty of care that a practitioner has However, it is incumbent on all critical care nurses, as
in providing treatment to a patient. Obtaining consent is patient advocates within the critical care areas of
part of the overall duty of care. 11 ICU, CCU and the emergency department (ED), to be
aware of the potential impact and possible outcomes
In recent decades, research in the biomedical sciences has of therapies delivered in the critical care environment.
been increasingly located in settings outside of the global Safe delivery of those therapies is often the nurse’s respon-
north. Much of this research arises out of transnational sibility, which is distinct from the medical order issued
collaborations made up of sponsors in high income to commence the treatment.
countries (pharmaceutical industries, aid agencies, chari-
table trusts) and researchers and research subjects in low- An understanding of the principle of consent is necessary
to middle-income ones. Research may well be carried out for nurses practising in critical care. Because of the vulner-
in populations rendered vulnerable because of their low able nature of the critically ill individual, direct informed
levels of education and literacy, poverty and limited consent is often difficult, and surrogate consent may be
access to health care, and limited research governance. the only option, particularly in an emergency. Consent
The protections that medical and research ethics offer in may relate to healthcare treatment, participation in
these contexts tend to be modelled on a western tradition human research and/or use and disclosure of personal
in which individual informed consent is paramount and health information. Each of these types of consent has
are usually phrased in legal and technical requirements. differing requirements. 19
When science travels, so does its ethics. Yet, when cast Consent to treatment
against a wider backdrop of global health, economic
inequalities and cultural diversity, such models often A competent individual has the right to decline or accept
2,3
prove limited in effect and inadequate in their scope. healthcare treatment. This right is enshrined in common
Attempts to address both of these concerns have gener- law in Australia (with state to state differences), and in
ated a wide range of ‘capacity-building’ initiatives in the Code of Health and Disability Consumers’ Rights in
13,20
bioethics in developing and transitional countries. New Zealand (1996). It is the cornerstone of the legal
Organisations such as the Global Forum for Bioethics in administration of healthcare treatment. With the intro-
21
Research, the Forum for Ethical Review Committees in duction in the UK of the Human Rights Act there is
the Asia Pacific Region and the World Health Organiza- increasing public awareness of individual rights, and in
tion have sought to improve oversight of research pro- the medical setting people are encouraged to participate
jects, refine regulation and guidance, address cultural actively in decisions regarding their care. Doctors daily
variation, educate the public about research and make judgements regarding their patients’ competency to
strengthen ethical review committee structures according consent to medical investigation and treatment, and in
to internationally acknowledged ‘benchmarks’. 4,5 today’s litigious climate they must face the possibility
that, from time to time, these decisions will be examined
The guidelines from the Council for International Organi- critically in a court of law. Capacity fluctuates with both
zations of Medical Sciences (CIOMS) – a body established time and the complexity of the decision being made;
jointly by WHO and UNESCO – take the position that thus, sound decisions require careful assessment of indi-
research involving human subjects must not violate any vidual patients.
universally applicable ethical standards, but acknowledge Accounts of informed consent in medical ethics claim
that, in superficial aspects, the application of the ethical that it is valuable because it supports individual auto-
principles, e.g. in relation to individual autonomy and nomy yet there are distinct conceptions of individual
informed consent, needs to take account of cultural values, autonomy, and their ethical importance varies. Consent
while respecting absolutely the ethical standards. provides assurance that patients and others are neither

Related to this issue is that of the human rights of research deceived nor coerced. Some believe that the present
subjects, as well as of health professionals as researchers debates about the relative importance of generic and spe-
in a variety of sociocultural contexts, and the contribu- cific consent (particularly in the use of human tissues for
tion that international human rights instruments can research and in secondary studies) do not address this
make in the application of the general principles of ethics issue squarely, believing that since the point of consent
to research involving human subjects. The issue concerns procedures is to limit deception and coercion, they
largely, though not exclusively, two principles: respect for should be designed to give patients and others control
autonomy and protection of dependent or vulnerable over the amount of information they receive and the
22
persons and populations. opportunity to rescind consent already given. There is a
professional, legal and moral consensus about the clini-
In order to provide safe patient care, clear internal systems cal duty to obtain informed consent. Patients have cogni-
and processes are required within critical care areas, as tive and emotional limitations in understanding clinical
with any other healthcare service provision. Critical care information. Such problems pose practical problems for
nurses need to be aware of the relevant policies and pro- successfully obtaining informed consent. Better commu-
cedures to have an understanding of their individual obli- nication skills among clinicians and more effective edu-
gations and responsibilities. Primarily, it is the treating cational resources are required to solve these problems.
medical officer who is legally regarded as the only person Social and economic inequalities are important variables
able to inform the patient about any material risks associ- in understanding the practical difficulties in obtaining
ated with a clinical therapy or intervention. 18 informed consent. Shared decision making within