My Take on “The Nurse Who Thought the ANA Code of Ethics for Nurses Was Wrong”

My Take on “The Nurse Who Thought the ANA Code of Ethics for Nurses Was Wrong”

Martha Levy finds herself torn between her professional code of ethics and her religious morality. On the one hand, her professional morality (as expressed in the ANA Code of Ethics) emphasizes the importance of patient autonomy. One widely accepted aspect of respecting patient autonomy is that a patient should not be forced to endure a treatment or procedure which they autonomously do not wish to undergo or continue. In this case, we do not hear Mr. Carson’s wishes directly from his mouth. However, his niece is his recognized surrogate and voice for his autonomous wishes. This form of surrogacy has become legally and ethically accepted practice in current medicine and health care. And so, ethically speaking, unless one can show reason otherwise, the decisions of Mr. Carson’s niece are accepted as his decisions as well. On the other hand, her religious morality (or at least the extent to which she and her rabbi interpret this morality) holds that life should always be preserved. This interpretation includes life in the debilitated state that Mr. Carson represents. And presumably this includes also treatments that many would consider torturous and not conducive to “quality of life.” This comprises what is sometimes called a “sanctity of life” view, in which life is recognized as having an “absolute” value, that is, not one qualified by condition or quality. I.e., life is valuable in itself, no matter its condition and should be preserved regardless of circumstances.

At the heart of this conflict is the question of the authority and meaning of these two moral views. One addresses a particular, limited area of life, i.e., nursing. The other, religious morality, applies to one’s life in general. One might also argue that religious morality in a sense “cuts deeper” as it includes deep, metaphysical beliefs and issues regarding one’s soul. However, professional ethics includes important elements regarding one’s professional life and status. And professional consequences can befall those who ignore or contravene published professional ethics—consequences such as loss of license. So this is not a simple conflict. It cuts deep on both sides.

This then leads to questions of moral authority regarding both approaches to morality. That is, from where do these moral codes draw the right to say what is moral and what is not; and from where does the responsibility of people to obey these moral codes come from? Regarding religious morality, the presumption is that the moral authority comes from God, from the deep devotion of believers in the spiritual, metaphysical, and moral foundation of a particular religion. This suggests very deep and important elements of a person’s life. However, this moral authority is only relevant to those who accept these foundations and beliefs, largely on a faith basis. Regarding the moral authority of a professional code of ethics, the authors of the text I borrowed this case from have this to say (in a commentary on this case):

Historically, some health professionals have claimed that the professional group actually creates the ethical duties for its members. Insofar as one wants to be a member in good standing, one would consider the profession’s judgment definitive. Others have argued, however, that ethics simply cannot be invented by any group of human beings, that what is ethically required must be grounded in some source beyond mere convention—in reason or universal moral law…(Fry, Veatch, & Taylor, 2011, p. 39)

I tend more toward the latter view. If the ethics of nurses were merely “created” by the ANA, that would, I believe, hold little true authority. In fact, I address this point in my paper, “The Role of the American Nurses Association Code in Ethical Decision Making.” Following Baker (2005), I describe the standards of the ANA Code as “discovered” rather than “invented” (or “created” to echo Fry, Veatch, & Taylor’s language) (Dahnke, 2009). That is, there is an understanding of what is and is not moral discoverable through rational analysis. These values are not simply and seemingly arbitrarily created or invented by some group. The authority of a professional code, then, is based on the considered moral judgment of a presumably well-intentioned group of professionals with the experience to understand what the ethical challenges and responsibilities of that profession are. At the same time, however, since this is a code created by humans, it is fallible and open to error. I even address the possibility that the Code could be wrong, and a nurse may be moral right and morally justified in violating it. There was a time nursing ethics assumed an imperative of nurses to follow a physician’s orders. However, if in a particular case a nurse judges a physician’s orders as clinically and/or morally wrong, s/he would be justified in refusing such an order but at the same time violating presumed nursing ethics. But, given the presumption that the ANA Code was written by thoughtful, experienced, well-meaning professionals, one can hold that it is presumptively correct—that is, morally correct until one can definitively demonstrate where it is mistaken.

However, here we may not be dealing with a case in which the ANA Code is mistaken but merely inconsistent with one version of religious ethics. And so this becomes an important question of moral integrity for Martha Levy. In the ANA Code, Provision 5.3-5.4 emphasizes the important of personal moral integrity: “Authentic expression of one’s own moral point of view is a duty to self…Wholeness of character pertains to all professional relationships with patients or clients” (ANA, 2015, p. 20). “Integrity” indicates the quality of being held together in a stable manner. One who lacks moral integrity, then, is one who is torn apart morally speaking. If Martha Levy’s religious morality tells her one thing, and her professional morality tells her to do the opposite, then her moral integrity is at risk regardless of what she does. And so, given the fact that the Code indicates that the moral integrity of a nurse is important, simply saying that she should follow the ANA Code and participate in the removal of the g-tube is not a sufficient answer. So, the ANA Code also mentions the option of conscientious objection. This is the process of refusing to participate in an action due to deeply held moral beliefs. In this way, Martha Levy may be able to maintain moral integrity while respecting both moral codes.

However, conscientious objection (or sometimes called conscientious refusal) comes with certain qualifications and limitations. First, as noted in the ANA Code, “Conscience-based refusals to participate exclude personal preference, prejudice, bias, convenience, or arbitrariness” (ANA, 2015, p. 21). This is not just an edict of the ANA Code but a widely accepted limitation of the principle. The point is to ensure that the refusal is based on deep and important values, not superficial preferences or frivolous notions. Only deeply held and important values are strong enough to overturn accepted standards of professional ethics. The question then becomes whether Martha Levy’s refusal is based on “personal preference, prejudice, bias, convenience, or arbitrariness” or sincere and deeply held moral convictions. That can be open to some interpretation and may need discussion for particular cases. Second, though not noted by the ANA Code, it is widely accepted that if conscientious objection is invoked, it includes an obligation to refer a patient to a provider who will provide the service the professional refuses to provide (assuming of course that the act in question is within the clinical and ethical standards of the profession). This leads to a third possible limitation and complication: what happens if no provider willing to do what the patient wants is available? That creates a deeper problem, which results either in the patient’s autonomy being violated or the professional risking a loss of integrity. So that situation needs to be avoided if possible. And finally, what happens if what is being refused is a regular part of a professional’s duty—either general duties or duties particular to a specific post or role? That is, in Martha Levy’s case, if removal of artificial nutrition and hydration were a common act at her facility, her constant refusals could become an obstacle to smooth running of the facility and quality and consistent care of patients. Now, this probably is not the case in most nursing homes, but it is still a possibility. If Martha Levy were working in a hospice, then clearly this situation would be a more common event. So, if it were a common part of the daily practice, then the best ethical decision, if possible, might be for Martha Levy to seek a position in which this act does not constantly arise.

So, ultimately, I believe Martha Levy’s refusal is likely based on deeply held moral beliefs and then potentially covered by conscientious objection. If she were to refuse, the question then becomes who is available to provide care in place of her. If there is no one, then that deepens the conflict. And if this becomes a repeating problem, Martha Levy should consider another area of nursing in which removal of g-tubes and other life-sustaining treatment would be less likely to occur.

References

American Nurses Association (ANA). (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Nursesbooks.org.

Baker, R.A. (2005). A draft model aggregated code of ethics for bioethicists 1. American Journal of Bioethics, 5(5), 33-41.

Dahnke, M.D. (2009). The role of the American Nurses Association Code in ethical decision making. Holistic Nursing Practice, 23(2), 112-119.

Fry, S.T., Veatch, R.M., & Taylor, C. (2011). Case studies in nursing ethics, 4^th edition. Sudbury, MA: Jones & Bartlett.