Six Ethical Principles Based on Human Dignity and Respect Study
Resource
Respect for humans as a function of human dignity is the primary ethical responsibility for nurses in practice.
The Code of Ethics for Nurses states that “the nurse practices with compassion and respect for the inherent dignity,
worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal
attributes, or the nature of health problems” (ANA, 2015a). Respect for persons requires that each person be
valued as a unique individual equal to all others and that every aspect of a person’s life is valued. This can be
difficult, because it is sometimes hard to value those parts of human lives that differ from our own. Human
dignity and respect for persons are the foundation of the six ethical principles discussed in this section:
autonomy, beneficence, nonmaleficence, justice, fidelity, and veracity.
Autonomy
The principle of autonomy asserts that individuals have the right to determine their own actions and the freedom to make
their own decisions. Respect for the individual is the cornerstone of this principle. Autonomous decisions are based on (1)
individuals’ values, (2) adequate information, (3) freedom from coercion, and (4) reason and deliberation. Autonomous
decisions lead to independent, autonomous actions. Autonomous actions by a patient include deciding to refuse treatment;
giving consent for treatment or procedures; and obtaining information regarding results of diagnostic tests, diagnosis, and
treatment options.
Regard for autonomy, however, is often missing in the health care system. Health care professionals often take actions
that affect patients’ lives profoundly without adequate consultation with the patients themselves. Some health care providers,
including physicians and nurses, may operate unknowingly in a paternalistic way that assumes that health care providers are
better equipped than patients to make health care decisions for patients. Some patients, however, prefer to have decisions
made for them, possibly because of a lack of information, fear of making a poor choice, or trusting that a care provider will
make the right decision for them.
Incorporating the principle of autonomy in all health care situations can be difficult. Autonomy poses a problem for
health care workers when the patient is incompetent to make decisions because of physical condition, psychological or
mental status, or developmental age. Examples of those unable to participate in decisions include infants or small children,
mentally incompetent patients, and unconscious patients. Other patients may be unable to participate in decision making
because of external constraints, such as the lack of necessary information, or the norms of their culture. Nevertheless, the
principle of autonomy is an increasingly important principle in health care and nursing.
Beneficence
Beneficence is commonly defined as “the doing of good” and is one of the critical ethical principles in health care. In
determining what is “good,” nurses should always consider one’s actions in the context of the patient’s life and situation.
Although this sounds simple, health care providers are challenged daily when what is good for the patient may also cause
harm to the patient or 135is in conflict with what the patient wants. Suppose, for example, that an elderly patient has become
confused, especially at night, and is at high risk for falls. She has fallen at home twice. Now that she is confused, she is at
even more risk for a fall, especially because confusion can become worse at night in the elderly. The health care team decides
that the patient needs a sitter to stay with her in her room all night. The patient objects stridently, because she is very dignified
and proud and enjoys her privacy. She complains that she “doesn’t need a babysitter” and cries for a long time. The patient
is prevented from falling but is psychologically distressed because of limitations on her independence, freedom, privacy,
and dignity.
Virtually everyone would agree that promoting good and avoiding harm are important to all human beings—and certainly
to health care professionals. It may seem surprising, therefore, how often conflicts occur surrounding the principle of
beneficence. A beneficent act may conflict with other ethical principles, most often autonomy. Even though a nurse or
physician may understand that a particular treatment has a benefit for the patient, the patient may decide to forgo that
treatment (autonomy) for a variety of reasons. In this instance, the health care provider should avoid acting paternalistically
and recognize that the patient remains in a position of self-determination.
Nonmaleficence
Nonmaleficence is defined as the duty to do no harm. This principle is the foundation of the medical profession’s Hippocratic
Oath; it is likewise critical to the nursing profession. Inherent in the Code of Ethics for Nurses (ANA, 2015a), the nurse must
not act in a manner that would intentionally harm the patient. Although this point appears straightforward, the nature of
health care dictates that some therapeutic interventions carry risks of harm for the patient, but the treatment will eventually
produce great good for the patient. Classic examples of this are chemotherapy and bone marrow or stem cell transplantation
procedures. Both interventions can make patients sicker for a time, posing a risk for complications such as opportunistic
infections, but the possibility of achieving a cure or remission of disease may justify the temporary harm. The concept that
justifies risking harm is referred to as the principle of “double effect.”
Double effect considers the intended foreseen effects of actions by the professional nurse. The doctrine states that as
moral agents we may not intentionally produce harm. It is ethically permissible, however, to do what may produce a
distressful or undesirable result if the intent is to produce an overall good effect (Beauchamp and Childress, 2001).
According to Guido (2006, p. 6), four conditions must be present to justify the use of the double effect principle:
1. The action must be good or at least morally indifferent (neutral).
2. The health care provider must intend only the good effects.
3. The undesired effects cannot be a means to the end or good effect.
4. There is a favorable balance between desirable and undesirable effects.
Justice
The principle of justice is that equals should be treated the same and that unequals should be treated differently. In other
words, patients with the same diagnosis and health care needs should receive the same care, and those with greater or lesser
needs should receive care that is appropriate to their needs.
Basic to the principle of justice are questions of who receives health care and whether health is a right or a privilege.
These questions have been central to discussions surrounding health care reform in the United States in the past several
years. Such questions involve the allocation of resources: how much of our national resources should be appropriated to
health care; what health care problems should receive the most financial resources; what persons should have access to
health care services?
Numerous models have been developed for distributing health care resources. These models include the following
(Jameton, 1984):
• To each equally
• To each according to merit (this may include past or future contributions to society)
• To each according to what can be acquired in the marketplace
• To each according to need
You may disagree with each or all of these models of resource distribution; certainly no single one is adequate in ensuring
a just model for the distribution of health care resources. In an ideal world, all people would receive all available treatment
and resources for their health needs, including disease prevention and health promotion. Unfortunately, this is not possible
because of costs and limited resources. When people with wealth have advantageous access to the best quality health care
available, which may include lifesaving medical devices or innovations, how does one apply the concept of justice?
Conversely, how does the issue of justice apply when access to 136care that is known to be cost-effective and simple, such
as prenatal care, is difficult or impossible for working-class women who are on the job during clinic hours?
Health disparities among ethnic minorities with regard to types of treatments and services that are available represent a
difficult problem in terms of an ethic of justice. Research has demonstrated that allocation of resources in the health care
system is not equitable among racial groups and that “racial disparity exists in health care access, treatment options and
outcomes” (Harrison and Falco, 2005, p. 252). Thinking Critically Box 7-3 describes lessons learned by nursing students
who participate in international learning experiences and how to continue one’s growth of social consciousness and sense
of justice.
Furthermore, how does one decide what is just when a natural disaster strikes, crippling health care facilities, and
providers are left with critically ill patients in dire circumstances? The situation of Memorial Medical Center (now Oschner
Baptist Medical Center) in New Orleans, Louisiana, in the aftermath of the devastating Hurricane Katrina in 2005 brought
these questions of justice and ethical decision making in a disaster to the general public in a way that was unprecedented in
modern American history. Desperate health care providers were in a dire situation with no electricity, rising water,
unbearable heat, and no reasonable hope of rescue for their many patients, many of whom were critically ill even before the
hurricane struck. An investigation later found that nurses and physicians had administered lethal doses of morphine and
midazolam to more than 20 patients whom the providers determined were unlikely to survive the disaster. A physician and
two nurses were eventually charged with second-degree murder. The charges were dropped against the nurses and a grand
jury did not indict the physician. Other questions were raised related to whom nurses had primary ethical responsibilities
during the storm: their patients or their own families?
In 2015, the ANA sponsored an ethics symposium that featured an interactive address with Sheri Fink, MD, PhD, who
won the Pulitzer Prize for her book Five Days at Memorial, an investigation of the patients’ deaths after Katrina. Dr. Fink
noted that thinking about situations in disasters in advance is a way to prepare for the troublesome ethical situations that
arise under 137conditions that are barely imaginable under normal circumstances (ANA, 2015b).
THINKING CRITICALLY BOX 7-3
To Keep the Vision of Social Justice
Nursing students often have a great deal of interest in and energy for international learning experiences. These experiences
expose students to the huge gap in health care practices and availability between developed and undeveloped nations. In an
article by Kirkham, Van Hofwegen, and Pankratz (2009), they describe the challenge of “keeping the vision” for nursing
students and their faculty as they return home—sustaining the social consciousness that is raised during these international
experiences.
Kirkham and colleagues (2009) defined social consciousness in terms of “personal awareness of social injustice,”
borrowed from Giddings (2005, p. 224). Specifically, they described social injustice as unfairness in the burdens and rewards
of a society in which there is inequitable access to health care services. Social injustice is the foundation of health disparities,
a serious ethical issue that challenges the human right to health and health care.
In their study of student learning that took place in international settings and the long-term benefits and effects of these
experiences, Kirkham and colleagues sought to describe students’ experiences but also to find ways to integrate and maintain
the students’ learning once they returned home (in this case, Canada).
Students had many experiences that opened their eyes to the health care practices and accessibility of care in an
underdeveloped country (Guatemala). Students related the realization that “statistics … became faces of people I know”
(p. 6) and that “people are the same everywhere” (p. 6). They also recognized the significant prosperity and power gradients
that exist between North and Central America. From these realizations, the students began to have a deep sense of social
injustice and the consequences of short-term international efforts that are not sustained. These insights challenged the
students’ worldview.
Despite the immense learning and intense reflection that resulted from these experiences, “keeping the vision” became
hard as students returned home. Kirkham and colleagues (p. 9) suggested four strategies that may help students in translating
their learning and sustaining their new vision for social justice. Individually, students can write journals of their reflections
and insights, read journals, and maintain contact with their host families. In formal groups, students can mentor new students
who will go through the same experiences, participate in forums and focus groups, and become involved in other
humanitarian projects. In informal groups, students can reflect on and share their experiences with other students and faculty
who participated in the international experience. And last, nursing school curricula can be shaped to integrate themes of
social justice.
Data from Kirkham SR, Van Hofwegen L, Pankratz D: Keeping the vision: Sustaining social consciousness with nursing students following international learning
experiences, Int J Nurs Educ Scholarsh (online) 6(1):article 3, 2009.
Justice as a principle often leaves us with more questions than answers. It raises our consciousness in identifying unjust
situations and in shaping resolutions to those situations, but applying the principle of justice does not determine what the
answer should be. A single ethical principle cannot typically be used to resolve complex ethical dilemmas such as those
encountered in health care settings.
Fidelity
The principle of fidelity refers to faithfulness or honoring one’s commitments or promises. For nurses, this specifically refers
to fidelity to patients. Through the process of licensure, nurses are granted the privilege to practice. The licensure process is
intended to ensure that only a qualified nurse, appropriately trained and educated, can practice nursing. When nurses are
licensed and become a part of the profession, they accept certain responsibilities as part of the contract with society. Nurses
must be faithful in keeping their promises of respecting all individuals, upholding the Code of Ethics for Nurses (ANA,
2015a), practicing within the scope of nursing practice, keeping nursing skills current, abiding by an employer’s policies,
and keeping promises to patients. Fidelity entails meeting reasonable expectations in all these areas. Fidelity is a key
foundation for the nurse-patient relationship. When nurses receive patient assignments and accept hand-off reports on those
patients, they are committed to providing care to those assigned to them. Failure to carry out the prescribed care is unethical
(provided that the prescribed care is safe and consistent with good practice) and may constitute patient abandonment or
neglect. This is a serious charge that would likely require state board of nursing review of the specific details of the case to
determine whether the nurse failed to carry out this responsibility ethically.
Fidelity suggests that one is faithful to the promises, agreements, and commitments made. This faithfulness creates the
trust that is essential to any relationship. Most ethicists believe there is no absolute duty to keep promises, however. In every
situation, the harmful consequences of the promised action must be weighed against the benefits of promise keeping
(Burkhardt and Nathaniel, 2002). This is an ethical posture that may explain decisions by some nurses during Hurricane
Katrina, described earlier, to stay at home with their families rather than going to the hospitals for their shifts.
Veracity
Veracity is defined as telling the truth, or not lying. Truth telling is fundamental to the development and continuance of trust
among human beings. Telling the truth is expected. It is necessary to basic communication, and societal relationships are
built on the individual’s right to know the truth, or not to be deceived. Inherent in nurse-patient relationships is the
understanding that nurses will be honest with their patients. However, in some (rare) instances nurses are constrained in
some health care systems that place limits on what a nurse can tell a patient. These situations, however, can pose an ethical
dilemma for nurses who believe that it is unethical to withhold information from patients, especially when patients ask for
information about their condition or diagnosis. A nurse can still remain truthful by telling the patient, “Dr. Roberts always
prefers to discuss her findings with her patients directly. I will page her and ask when you can expect her to make rounds
tonight to talk to you.” Intentional deception, however, is considered morally wrong. (Consider the situation again of
Michelle, the nurse who was challenged by Mrs. Thomas, her patient’s wife, about whether she had even called a social
worker yet: caught in a lie, what was the best thing Michelle could do?)
Some health care providers attempt to justify deceiving their patients. For the most part, these justifications are related
to the idea that patients would be better off not knowing certain information or that they are not capable of understanding
the information. This reflects a posture toward patients known as “paternalism,” in which someone believes that he or she
knows what is best for another person who is competent to make his or her own autonomous judgments about a course of
action. Some justify not being truthful with a patient if they perceive that the patient might refuse medical treatment if he or
she knew the “complete” truth. However, if both patient and health care provider are respectful of each other as individuals,
it is difficult to accept that deception is ever justified. Two exceptions exist, however. If a patient asks not to be told the
truth, the nurse can, under the ethical principles of beneficence and nonmaleficence, withhold the truth. This does not mean
that the nurse must lie but that the nurse is released from obligation to report to the patient what he or she may know.
Furthermore, if a patient is mentally incompetent, autonomy and the capacity for self-determination are diminished, thereby
justifying withholding of health care information.
Hines (2008) made an interesting observation that true cultural humility (a posture that requires that clinicians make
every effort to understand their patients’ beliefs and how their patients want themselves and their illness to be treated) is tied
to respecting patient preferences for information and for treatment. Although 138Hines was writing about care in an
oncology setting, her observation that “goals of care can be established, refined, or refocused at any point in the trajectory
of care, whether truth telling or not telling is occurring” (p. 415) holds true for any practice setting for nurses.