Ethical Issues

Introduction

Ethical issues are of concern to all nurses. Rehabilitation nurses, in particular, encounter challenging ethical situations in the settings in which they practice. Nurses provide care to promote the health and well-being of individuals; this implies interactions among people, and it implies the seeking out of what is good and of what leads to health and welfare. “Ethics” is a formal decision-making process, used to determine the rightness of conduct. “Morals” refer to the rules and principles of right conduct (Blais, et al.). The ethical standard for the profession of nursing is established in the Code of Ethics for Nurses with Interpretive Statements (American Nurses Association, 2001).

Ethical dilemmas are created when a choice must be made between difficult alternatives or when important principles conflict. Nurses practicing in the specialty of rehabilitation are confronted with numerous ethical dilemmas. Members of the Association of Rehabilitation Nurses (ARN) have identified several ethical issues that are of concern to those practicing rehabilitation nursing, including the following: 

1. Patients’ rights, including the rights of minors. (Minors are capable of understanding the decisions made in their name by their parents. If a minor was not involved in the decision-making process and does not agree with his or her parents’ decision, the minor may have no recourse regarding that decision, which leads to an ethical and legal conflict.)
2. The use of restraints
3. Do-not-resuscitate orders
4. Advance directives, which imply nursing intervention and responsibility regarding living wills and durable power of attorney
5. Management of clients who are disposed to self-destructive behaviors or suicidal gestures
6. Issues related to healthcare reform and changes in how healthcare is allocated and delivered including, but not limited to:
   • access to health care and rehabilitation
   • cost containment
   • determining length of stay
   • defining who meets the criteria for rehabilitation
   • dealing with patients’ noncompliance with treatment and rehabilitation
   • Patient and family teaching in preparation for discharge to home or another level of care
   • Transition to care level with appropriate skills for patients’ needs
7. Confidentiality, security, and privacy related to patient care
8. Substance abuse
9. Abused patients
10. The nurse/client relationship, e.g., when does it become too intimate, and when is intimacy between the nurse and the client appropriate?

Because ethical issues are of great concern for rehabilitation nurses, the Association of Rehabilitation Nurses developed this position statement.

Position Statement

The Association of Rehabilitation Nurses supports the 2001 ANA Code of Ethics for Nurses with Interpretive Statements and The Patient Care Partnership (2003) of the American Hospital Association as important guides for ethical decision making. ARN makes the following additional statements:

1. The rehabilitation nurse acts as a patient advocate.
2. The rehabilitation nurse recognizes the importance of patients’ participation in the decision-making process and realizes that some patients do not and will not value independence and wellness as much as the rehabilitation professional does.
3. The rehabilitation nurse is concerned about the rehabilitation patient’s quality of life as defined by the patient, if technological advances in healthcare are compromising it. Advanced medical technology may prolong life but not improve the quality of life.
4. The rehabilitation nurse is responsible for providing information or assisting with the collection and interpretation of information that is necessary to resolve major ethical dilemmas and assist in the patient’s decision-making process.
5. The rehabilitation nurse stays informed about ethical issues that might affect rehabilitation patients and is aware of his or her own values and attitudes.
6. The rehabilitation nurse, practices with compassion and respect for the dignity, worth of every individual, in a nonjudgmental and nondiscriminatory manner.
7. The rehabilitation nurse bases his or her decisions on the ethical principles of autonomy, beneficence, justice and nonmaleficence.
8. The rehabilitation nurse participates in research and realizes that the benefits of research and human experimentation carry certain threats to human rights. To protect these rights when participating in research, the nurse considers the issues of informed consent, criteria for inclusion and retention of subjects, training of researchers, research dissemination, ethical supervision and accountability, and provisions for subjects’ privacy and the confidentiality of results and findings.
9. The rehabilitation nurse participates in decision-making regarding allocation of resources used by or for the patient.

Regarding the rights of patients, the Association of Rehabilitation Nurses holds the following beliefs:

1. All people have the right to receive rehabilitation services regardless of their age, race, gender, ethnicity, religion, or economic status.
2. All patients have the right to receive full resuscitation, request do not resuscitate orders, request the discontinuation of life support measures, or refuse recommended treatment, as long as they fully understand what they are requesting.
3. All patients’ medications used to improve their ability to participate in rehabilitation will be accompanied by a defined plan of care with targeted outcome.
4. All patients have the right to expect modification to their environment to promote their safety. If environmental modifications prove unsuccessful, patients have the right to expect that the least restrictive restraint device may be used to prevent risk from harm. Use of environmental modifications and/or restraints will be accompanied by a defined plan of care targeted at restraint reduction outcomes.
5. All patients have the right to expect the patient education process to include health information and instruction that is applicable to the patient’s care needs as well as information needed to make decisions about discharge plans. These decisions may include resources for discharge to home or another level of care.

References

American Nurses Association. (2001). Code of Ethics for Nurses with Interpretive Statements. Retrieved from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.pdf.

American Hospital Association. (2003). The Patient Care Partnership. Retrieved from http://www.aha.org/advocacy-issues/communicatingpts/pt-care-partnership.shtml.

Blais, KK, Hayes, JS, Kozier, B., Erb, G, (2010). Professional Nursing Practice: Concepts and Perspectives (6th Edition). Upper Saddle River, NJ: Prentice Hall.

Jacelon, CS (Ed.). (2011). The Specialty Practice of Rehabilitation Nursing: A Core Curriculum (6th Edition). Glenview, IL: Author.

Oermann, M.H. (1997). Professional Nursing Practice. Stamford, CT: Appleton & Lange.

Approved by the ARN Board of Directors September 1994; revised October 2003; revised April 2014.