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• To refresh your understanding of the four principles of biomedical ethics
• To understand how these principles are linked to the standards in the Nursing and Midwifery Council Code
• To enhance your knowledge of the use of ethics in decision-making in nursing
Nurses are regularly confronted with moral questions and ethical dilemmas in their practice, for example where a patient’s decisions about their treatment conflict with the nurse’s own views. While the standards contained in the Nursing and Midwifery Council The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates provide nurses with an overarching framework to guide practice, it is important that nurses understand the four main principles that underpin ethical care – autonomy, beneficence, non-maleficence and justice. This article examines these four principles and how they relate to nurses’ ethical decision-making. The author also explores how nurses’ ethics were tested by the coronavirus disease 2019 (COVID-19) pandemic. Having an awareness of ethical decision-making can enhance nurses’ practice by providing them with a theoretical framework for treating patients with dignity and respect.
Nursing Standard. doi: 10.7748/ns.2024.e12346
Correspondence Conflict of interestNone declared
Dunn H (2024) Ethical decision-making: exploring the four main principles in nursing. Nursing Standard. doi: 10.7748/ns.2024.e12346
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Published online: 22 July 2024
Nurses are confronted with moral questions and ethical dilemmas in their practice on a day-to-day basis. They may have to decide what course of action to take when a patient refuses treatment or be forced to prioritise the care of one patient over another due to inadequate staffing levels. As a concept, ethics is concerned with the foundational principles a person needs to exhibit if they are to live a ‘good’ life and involves other concepts such as obligation, duty, justice and virtue. Essentially, ethics is concerned with the actions that a person chooses and how these affect other people (Hemberg et al 2019).
The concepts of ethics and morality are closely related but have different meanings. Morals comprise the beliefs and values that people hold about what is ‘right and wrong’, while ethics involves the identification of what is right or wrong (Olsen 2017). Ethics also represents an ever-changing ideal. What was considered ethical 20 years ago may not be considered ethical today and consequently people’s moral values must adapt to societal changes. Ethics is not static and can be influenced by significant events, such as the coronavirus disease 2019 (COVID-19) pandemic, which involved significant moral and ethical questions around issues such as people’s individual choice about whether to be vaccinated. This issue was discussed by Maneze et al (2023), who explored the ethical need to balance the rights of the public against the moral obligations of healthcare workers to protect the population during a public health emergency.
A nurse’s ethical behaviour should derive from a strong moral dimension that directs them to act consistently in what they understand to be the ‘right way’ (Mannix et al 2015). However, defining right or wrong in healthcare is not always clear-cut; for example, some nurses may regard the provision of cosmetic surgery on the NHS as ‘wrong’, whereas other nurses may consider such a use of healthcare resources as justified.
Nurses’ individual beliefs and morals will determine how they approach challenging situations (Johnstone and Hutchinson 2015). For example, although illegal in the UK, some nurses may feel assisted suicide is the patient’s choice and is morally correct. However, nurses have an obligation to resolve their own moral issues when caring for patients and will need to adopt the standards of ethical behaviour required by the nursing profession even if this clashes with their own view. The Nursing and Midwifery Council (NMC) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates provides an ethical guideline for nurses and demonstrates the principles of ‘good practice’ (NMC 2018).
Ethical competence in healthcare involves a nurse’s personal capacity to demonstrate ethical awareness, such as ensuring patients are treated equally and that suboptimal standards of care are not ignored (Kulju et al 2016). Beauchamp and Childress (2019) identified four principles of biomedical ethics that can be applied to nursing practice:
• Autonomy – represents the patient’s right to make decisions about their care.
• Beneficence – dictates that healthcare professionals must promote the best interests of the patient.
• Non-maleficence – refers to the healthcare professional’s obligation to ‘do no harm’ to the patient.
• Justice – represents the principle that everybody should have equal access to healthcare.
These four principles do not aim to provide answers to moral issues, but provide a framework for nurses to reflect on and use to assist them with ethical decision-making (Bryant 2020). Similarly, the four principles can be used by nurses to improve their understanding of the issues involved in an ethical dilemma. For example, when a patient declines medical treatment, the nurse will have to weigh up the need to respect the patient’s right to autonomy against their own obligation to act according to the principles of beneficence and non-maleficence (Mortensen et al 2019).
Nurses need to understand their own morals and how they can reflect Beauchamp and Childress’ (2019) four principles in their day-to-day care. Nurses should also strive to provide patients with the best care possible and should apply the principles with the aim of promoting health and alleviating harm, as well as considering the patients’ individual needs.
Ethical principles adapt to changing demographics and societal lifestyles, emphasising the need for nurses to constantly consider their moral framework and its effect on patients. For example, recent shifts in societal attitudes about gender have been reflected in healthcare in areas such as increasing demand for same-sex hospital wards. As society changes, so nursing roles will develop and change, one example being the focus on promoting healthy lifestyles and prevention of disease rather than relying on resource-heavy hospital care (Department of Health and Social Care 2024). Nurses must learn to adapt to these societal changes while continuing to practise Beauchamp and Childress’ (2019) four principles of biomedical ethics.
The Code (NMC 2018) contains a series of statements that taken together ‘signify what good practice by nurses, midwives and nursing associates looks like. It puts the interests of patients and service users first, is safe and effective and promotes trust through professionalism’.
Professional regulations, such as the Code (NMC 2018), can provide a template for guiding nurses’ professional conduct. The Code provides a set of standards that nurses should adhere to and which can be monitored and benchmarked; in addition, nurses can be held to account if these standards are not met (Davidson et al 2018, NMC 2018). Morals shift over time and so must the regulatory Code to ensure that it aligns with changes in society. If the regulatory Code that governs nurses’ professional behaviour was not updated, it would simply reflect the moral standards of the past.
Beauchamp and Childress’ (2019) four principles are linked to the Code (NMC 2018) in that they provide a guide for how individual nurses can value their fellow human beings and respect their relationships with others, but above all, protect patients’ rights. Box 1 provides a summary of how the four principles of biomedical ethics are reflected in the Code (NMC 2018).
By adhering to the Nursing and Midwifery Council Code, nurses will be acting in accordance with the four principles of biomedical ethics:
• Autonomy – the right of the patient to make their own decisions. Reflected in the ‘prioritise people’ standard in the Code, whereby nurses must ‘avoid making assumptions and recognise diversity and individual choice’
• Beneficence – promoting the best interests of the patient. The ‘prioritise people’ standard in the Code also concerns beneficence, with a focus on putting the patient’s interests first
• Non-maleficence – do no harm to the patient. The Code’s standards of ‘practice effectively’ and ‘preserve safety’ reflect this principle in that nurses must ‘work with colleagues to preserve the safety of those receiving care’ and ‘be aware of, and reduce as far as possible, any potential for harm’ associated with their practice
• Justice – ensuring fairness, balance and legality. This principle is reflected in the ‘prioritise people’ standard in the Code and involves acting as an ‘advocate for the vulnerable, challenging poor practice and discriminatory attitudes and behaviour relating to their care’ and respecting and upholding people’s human rights
(Nursing and Midwifery Council 2018, Beauchamp and Childress 2019)
Autonomy is linked to person-centred care and the principle that patients should be involved in decisions about their treatment. A nurse must respect the patient’s morals and right to autonomy by providing adequate information to enable them to make their own decisions based on their own beliefs and values, even where these differ from those of the nurse. The Code (NMC 2018) reinforces patients’ autonomy by requiring nurses to obtain their consent for any treatment or procedures, with standard 4.2 requiring nurses to ‘make sure that you get properly informed consent and document it before carrying out any action’.
The principle of autonomy is not without limits, as it relies on the patient having capacity in accordance with the Mental Capacity Act 2005, with informed consent being the foundation of treatment decisions (Wagner and Dahnke 2015, Craig et al 2018, Bryant 2020). If the patient lacks capacity, the nurse may have to make decisions in their best interests, with the overall intent of causing the least harm possible (Podgorica et al 2021). However, section 1 of the Mental Capacity Act 2005 promotes autonomy through an initial presumption that an individual has the capacity to make decisions unless it can be demonstrated otherwise. Therefore, nurses should empower patients to participate actively in their own care and make decisions based on their individual circumstances and choices, while seeking to uphold their dignity. To make a fully informed decision, the patient needs to understand the risks, benefits and likelihood of success of any treatment (Lajiness 2021).
Nurses should remember that not all patients wish to make autonomous decisions. Similarly, nurses may find it challenging when patients make decisions that may harm their health, such as refusing to attend hospital appointments. Mortensen et al (2019) stressed that the patient should not be forced to make treatment decisions when they do not want to, or when they do not have the necessary capacity. In such situations, the nurse’s legal duty of care is to ensure the patient has all the information required so they can make a fully informed decision. Moreover, informed consent is designed to protect patients from abuse and exploitation and therefore requires that healthcare professionals disclose any information about treatment accurately and in a way the patient can understand (Schrems 2014). By ensuring that they provide patients with all the necessary information to make treatment decisions, and by not constraining their right to make informed choices, nurses can ensure that patients are treated with respect and that their autonomy is maintained (Bryant 2020).
With regards to children’s healthcare, patient autonomy relies on assessment of ‘Gillick competence’ (in England and Wales), which is used to determine whether a child under the legal age of consent (16 years) is sufficiently mature to make their own decisions and consent to medical treatments (Bryant 2020). Gillick competency involves consideration of a range of factors including, for example, the child’s age, maturity and mental capacity, and their understanding of the issue, including the benefits, disadvantages and potential long-term effects of any treatment and their understanding of alternative options. In Scotland, the Age of Legal Capacity (Scotland) Act 1991 gives medical practitioners authority to make a judgement about the level of understanding of a child regarding consent to a health procedure or treatment (Scottish Government 2023).
Although autonomy is a significant factor in ethical care, if the patient requests a treatment or intervention that contradicts the principle of non-maleficence (do no harm), the nurse should not feel obliged to operate outside the standards of the Code (NMC 2018). Furthermore, the COVID-19 pandemic demonstrated the removal of patient autonomy ‘for the greater good’, where the needs of the individual were sometimes superseded by the interests of the population at large (Vearrier and Henderson 2021).
The theme of advocacy is linked to autonomy and involves the nurse recognising their role as patient advocate (Barlow et al 2018). In this role, the nurse supports the patient’s wishes with regards to their treatment and/or decisions regarding health outcomes, which in turn promotes autonomy. Where a patient is considered to lack capacity to make autonomous decisions – for example, in a person with advanced dementia – they may be reliant on the nurse advocate to assist them in representing their views and beliefs in treatment decision-making processes (Cole et al 2014).
• Ethical competence in healthcare involves a nurse’s personal capacity to demonstrate ethical awareness
• Ethical principles adapt to changing demographics and societal lifestyles, so nurses need to constantly consider their moral framework and its effect on patients
• The four principles of biomedical ethics are linked to the Nursing and Midwifery Council The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates by providing a guide for how nurses can value their fellow humans, respect their relationships with others and protect patients’ rights
• Using the four principles of biomedical ethics in nurses’ decision-making promotes patient safety and advocacy and maintains the integrity of the nursing profession
Beneficence involves undertaking ‘good acts’ that benefit others, in this case the patient (Cheraghi et al 2023). Unlike non-maleficence, which involves simply doing no harm, beneficence obliges nurses to actively help others. However, the two principles are often seen as ‘two sides of the same coin’ with beneficence involving acts that benefit others and non-maleficence involving acts that avoid harming others (Cheraghi et al 2023).
Beauchamp and Childress (2019) defined beneficence as having three principles: preventing harm or pain; removing harm or pain; and acting to promote the patient’s best interests, such as providing pain relief. Practising beneficence means that the nurse has a duty to actively promote the patient’s best interests, defend their rights and remove any circumstances or conditions that will cause them harm (Bryant 2020). Nurses therefore have a moral obligation to contribute to the well-being of patients and act in their best interests at all times, as well as considering what is acceptable to them.
The ‘prioritise people’ standard in the Code (NMC 2018) concerns beneficence and nurses’ moral obligation to act for the benefit of their patients (Beauchamp and Childress 2019). Beneficence ensures that nurses consider the patient’s individual needs, while also accepting that what is in one patient’s best interests may not necessarily be in the interests of another. In the author’s opinion, beneficence can be summed up by asking oneself: ‘Does this action or decision benefit the patient?’
The ethical principle of non-maleficence dictates that the nurse does not cause harm to another person or patient (Beauchamp and Childress 2019) or at least minimises potential harm (You and Ulrich 2023). As well as avoiding actions that harm oneself or others (Cheraghi et al 2023), non-maleficence also involves a duty to avoid causing pain, suffering and disablement (Bryant 2020) or depriving others of the ‘goods of life’ (Beauchamp and Childress 2019).
Non-maleficence directs nurses to consider all the benefits of treatments and weigh them against the potential risks. Adhering to the principle of non-maleficence involves trying to ensure that the potential benefits of an intervention outweigh the potential harms (Craig et al 2018). Non-maleficence can appear simple to achieve initially; however, it is complicated by the fact that common nursing actions can cause pain and discomfort. For example, inserting a cannula can involve significant discomfort even though it usually has a justifiable clinical purpose. This demonstrates the presumption of ‘compensatory good’, which outweighs the pain and short-term harm caused and is warranted if the patient is to receive a longer-term benefit (Wagner and Dahnke 2015). As such, even routine decisions in nursing, such as whether to change a patient’s dressing, have an ethical basis. While changing a dressing may initially involve pain, it may reduce the risk of infection and sepsis and improve the patient’s outcomes, therefore the nurse must consider all of these eventualities. In this sense, all nursing decisions are ethical in nature (Milliken and Grace 2017).
For nurses, adhering to the Code (NMC 2018) reflects non-maleficence in the ‘practice effectively’ and ‘preserve safety’ standards; the Code makes clear that nurses must preserve the safety of those receiving care and reduce any potential harm as far as possible.
Bryant (2020) emphasised the difference between non-maleficence and beneficence, with non-maleficence dictating that the nurse refrains from harmful action, where beneficence requires positive action. The balance between these two principles is important in all nursing actions, but the basic principle of non-maleficence and ‘do no harm’ should take precedence in the nurse’s decision-making.
Although justice is often regarded as the fourth ethical principle, it is as important as autonomy, beneficence and non-maleficence. Justice reflects the need for a fair and equal distribution and allocation of healthcare resources in society (Bryant 2020), in which each person is regarded as deserving (Beauchamp and Childress 2019). In the author’s opinion, the main principles within the concept of justice are whether the proposed action is legal, whether it adversely affects the person’s human rights and whether it is fair and balanced.
Injustice can be seen in healthcare when certain treatments are available to some patients and not others, for example through a ‘postcode lottery’ of care provision (Edwards-Maddox et al 2022). Strøm and Engedal (2021) explained that the challenge for healthcare staff is how to offer everyone the same level of care based on the principle of justice while simultaneously taking individuals’ needs into consideration. This challenge is demonstrated by the need to sometimes refuse treatment when other patients are deemed to be of a higher priority and to do this in an ethical manner (Strøm and Engedal 2021). For example, the Institute of Cancer Research (2022) expressed disappointment at a National Institute for Health and Care Excellence decision that it was not cost-effective to recommend the cancer medicine olaparib for men with previously treated, hormone-relapsed metastatic prostate cancer, despite it being available to people with other forms of cancer.
For the nurse, demonstrating justice in their everyday practice can involve remaining impartial and non-judgemental in their relationships with patients, providing resources equitably and treating all patients fairly whatever their ethnicity, socioeconomic status, sexual orientation or physical and/or mental health status (Edwards-Maddox et al 2022). Demonstrating justice is enshrined in the Code (NMC 2018) in the ‘prioritise people’ standard, which states that nurses should ‘act as an advocate for the vulnerable, challenging poor practice and discriminatory attitudes and behaviour relating to their care’ and that they should always ‘respect and uphold people’s human rights’.
The COVID-19 pandemic brought about numerous dilemmas stemming from a conflict between the four principles of biomedical ethics, such as when the government rolled out a mandatory vaccination programme for all healthcare staff (Jalilian et al 2023). Maneze et al (2023) emphasised that mandating COVID-19 vaccination for healthcare staff was a complex issue and involved striking a balance between the rights of staff to exercise personal autonomy and the rights of the public to be protected during a pandemic. Ultimately, a decision was taken by the UK government to remove healthcare workers’ autonomy and introduce mandatory vaccination for the benefit of society as a whole (Jalilian et al 2023).
Similarly, a lack of trust in the beneficence and safety of the COVID-19 vaccines among certain sectors of the population stemmed from suspicion of scientific research, insufficient evidence and exposure to inaccurate information about the vaccines (Jalilian et al 2023). According to the principle of non-maleficence, therefore, researchers had to minimise the possibility of adverse effects from the various COVID-19 vaccines (Jalilian et al 2023).
The COVID-19 pandemic raised some other ethical issues, with short-staffing and a lack of resources combined with the volume of patients resulting in nurses having to make decisions about who to treat. Nurses are regularly exposed to morally distressing events and have to make ethically challenging decisions about patient care, such as prioritising the treatment of some patients over others during staff shortages. However, this was exaggerated during the pandemic with ethical dilemmas experienced by nurses on a daily basis (Rowlands 2021).
For nurses, stressful workplace environments, lack of staff and resources, and an inability to provide the standards of care they would like to, results in compromises when seeking to adhere to the four principles of biomedical ethics. This was seen during the pandemic where nurses lacked resources to treat all patients equally (affecting justice) and often experienced moral injury as a consequence of their inability to provide high-quality nursing care (affecting non-maleficence) (Rowlands 2021). During the pandemic, nurses’ working environment was unsafe due to a lack of personal protective equipment and the risk of infecting colleagues, other patients and family members. This further challenged the principle of non-maleficence and raised ethical questions, such as at what point did nurses begin to do harm through no fault of their own?
In less extreme circumstances than the COVID-19 pandemic, the use of the four principles of biomedical ethics in nurses’ decision-making promotes patient safety and advocacy and maintains the integrity of the nursing profession (Craig et al 2018). Respecting patients’ right to self-determination (autonomy), promoting their best interests (beneficence), preventing harm (non-maleficence) and allocating resources fairly and transparently (justice) should be the objectives for all nurses.
Ethics are ever-changing, but for nurses, questioning their own morals and adhering to the Code (NMC 2018) are vital factors in providing the best possible care for all patients. Ethics influence nurses’ duty of care on a daily basis; having an understanding of how to apply the four principles of biomedical ethics – autonomy, beneficence, non-maleficence and justice – will enable nurses to act in a professional manner while providing the best possible care to their patients.
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