Ethics In Practice Tension between Individual and Societal Rights Gail A. DeLuca Havens, PhD, RN Codes of ethics can be thought of as moral codes. Moral commitments to adhere to the ideals and moral norms of the profession, such as maintaining competency in practice, are expressed in the American Nurses Association (ANA) Code of Ethics for Nurses (2001, p. 5) and are made by individuals when they become nurses. The fundamental concept underlying the Code of Ethics for Nurses is respect for persons. Certain principles growing out of this concept guide nurses’ decision making. These include fostering self-determination, doing good, avoiding harm, being truthful, respecting privileged information, keeping promises, and treating people fairly. In their moral decision-making hierarchy, Beauchamp and Childress (2001) refer to principles and rules as action guides. Principles are the more global and basic conceptions that justify the rules. When ethical principles are being considered, it is important to remember that individuals are interdependent members of a community. The nurse will encounter situations in which the tension between individual liberty and the need to preserve the health and well-being of the community creates an ethical dilemma in practice. For instance, the nurse promises, as expressed by the principle of fidelity in the ANA Code, to maintain client confidentiality. However, such a promise is not absolute when innocent parties are in direct jeopardy (e.g., threatened with being killed) (ANA, 2001). This particular kind of dilemma is made even more troublesome for the nurse who is attempting to deal with two opposing or contradictory promises. For example, the implicit promise of the nurse to maintain client confidentiality, as expressed in the ANA Code, may contradict the nurse’s obligation to obey a law that requires reporting a particular situation (ANA, 2001). The nurse also has an ethical responsibility to respect the client and promote self-determination. Consider the following situation. Kay is a community health nurse who has been employed by a home health agency for more than 10 years. Several of her clients live in a homeless shelter and have been referred to her agency for follow-up tuberculosis treatment after hospital discharge. Today she is making her first visit to Paolo, a 33-year-old Hispanic man discharged after treatment in the hospital for acute, infectious tuberculosis. Kay explains that her agency, along with the city’s health department, helps persons with tuberculosis continue to take their medication as prescribed until they are cured. Kay asks Paolo how he is feeling this morning. He replies that he is tired; he did not sleep well this first night in a place not familiar to him. After she completes Paolo’s admission history and physical examination, Kay tells him that she, or a nurse substituting for her, will be visiting Paolo daily for 2 weeks to observe him taking his medication and then twice weekly for at least 6 months. Paolo protests that he is not a child and that he can be depended on to take his medication as prescribed. Kay explains that the current standard of care is that everyone in the community being treated for tuberculosis receive directly observed medication therapy. It will help him remember to continue to take medication as prescribed, particularly when he begins to feel better. Stopping the medication makes the treatment he received in the hospital ineffective. When medication is stopped, often the tuberculosis becomes infectious again. In addition, not completing treatment increases the likelihood that he will develop a type of tuberculosis that is resistant to medication therapy (Centers for Disease Control and Prevention [CDC], 2003a). He could be very ill again. The city has an obligation to protect its residents from becoming infected with tuberculosis. Kay tells Paolo that she will be communicating with health department personnel because they are the ones who referred him to her. Paolo agrees, reluctantly, to cooperate in therapy. He asks how long it will take to be cured. Kay knows that the response to therapy varies, but most persons can be cured within 9 months (CDC, 2003b). Kay explains that 6 months of medication has been prescribed to cure his tuberculosis. Before Kay leaves, Paolo takes his first dose of medication, and they establish a schedule for his observed daily self-administration. Paolo’s treatment continues as planned over the next several months. He gains strength and eventually finds a job. Returning to work requires that his medication regimen be modified. Paolo has no trouble adapting it to his more demanding schedule. Several weeks pass with this new arrangement until, one evening, Paolo does not appear. Kay leaves a message for him to call her, but does not hear from him. When Paolo fails to appear again the following evening, Kay returns to the shelter. Eventually, Kay learns that Paolo has not been complying with his prescribed medication regimen. He does not deny it and tells Kay that because he has been taking medication for more than 3 months and feels better, he believes that he is cured of his tuberculosis and no longer needs therapy. How should Kay respond? Should she respect Paolo’s right to self-determination by not interfering with the decisions he has made? What if Paolo were to be harmed by this noninterference? What if others were to be harmed? Does Kay’s obligation to Paolo to maintain confidentiality remain even when his behavior might compromise the health and well-being of others? Under what circumstances might a nurse place the health and well-being of members of a community before those of an individual client? In this situation, because Paolo is an adult who is responsible for his own health, Kay could simply disregard the fact that Paolo has not been adhering to his prescribed medication regimen. However, she would not be helping Paolo to protect himself or others. Another strategy that Kay might employ would be to engage Paolo in problem solving to further explore his reasons for not complying with the medication regimen. Uncovering reasons for noncompliance often results in identifying ways to avoid it. One of the strategies recommended for directly observed therapy is for the nurse to adopt a nonjudgmental attitude toward clients, acknowledging that individuals often will not be 100% compliant with medication regimens. Kay could acknowledge that, because Paolo is feeling better, it is understandable that he is not taking his medication as prescribed. However, she also ought to remind him that he places himself at great risk for getting very sick again and developing drug-resistant tuberculosis by not following his medication regimen. This course of action might also be an opportunity to foster Paolo’s self-determination, to maintain the confidential nature of his care, and to strengthen the client-nurse relationship. However, adopting this strategy does jeopardize Paolo’s health and the health of the people with whom Paolo comes in contact. Kay does not know whether Paolo’s tuberculosis is infectious. Kay initiates tuberculosis screening for the people with whom Paolo has been in contact and creates an opportunity for Paolo to have his tuberculosis reevaluated. This action ought to diminish the potential for harm from active tuberculosis to Paolo and to others with whom he has been in contact. Because Kay’s authority has been delegated to her by the health department, she can communicate with the health department without legally violating confidentiality. Kay is aware that many states require quarantine of individuals who do not successfully complete a medication regimen for tuberculosis. To protect the public, a community health nurse can recommend that formal action be taken to ensure that a person complies with treatment. In this instance, quarantine means that individuals can be hospitalized or incarcerated for treatment of tuberculosis against their will. As a third strategy, Kay can follow the established protocol to initiate quarantine, reporting Paolo’s lack of compliance with medication therapy to the appropriate people. However, this breaches the confidential nature of the clientnurse relationship and compromises the trust and mutual respect that have been established between Paolo and Kay. The ANA Code (2001) alerts nurses to the reality of suspending individual rights but warns that this ought to be considered a serious deviation from the standard of care (p. 9). Usually, a nurse does not select the third alternative until the second alternative has proven ineffective. How might Paolo be affected by this experience? How might Kay be affected by this experience? Which alternative would you choose? Should individual rights be compromised to control the spread of communicable diseases for the good of society? What is the role of boards of health in your community and state in preventing and controlling communicable diseases?