Nursing Ethics: Confidentiality, Culture, and Patient Autonomy

Introduction: Ethics in the Nursing Profession

The nursing profession, perhaps more than any other, is a veritable minefield of ethical issues and dilemmas. Because it is a caring profession, the focus of nursing is its clients and their care. Hence, nurses often need to distinguish between their personal values, their professional values, and what is commonly accepted as the ethical viewpoint. In ethical dilemmas, these distinctions become vague, and critical thinking in nursing ethics becomes of utmost importance.

Complicating the issue further is the role of culture and its impact on values. Relationships and personal ethics vary among cultures, and nurses often find themselves needing to be aware of this. In order to make a truly ethical decision when faced with vague guidelines and competing values, the nursing professional must also take cultural values into account. In the case of Mr. and Mrs. Z, for example, the issue does not only concern the commonly held nursing ethic of doing no harm, but also the individual's right to autonomy and the cultural relationships surrounding Mrs. Z.

The focus of the nursing profession is its clients. More than most other professions, nursing involves ensuring that people become not only as physically well as possible, but also that they are emotionally supported throughout the healing process. Because there are many different types of values and viewpoints in the world, nursing often becomes a battleground of conflicting ethical concerns. For this reason, a common set of ethics is important to help the nursing professional in the decision-making process, and also to honor age-old professional values such as doing no harm.

Ethical Theory and Nursing Values

According to Marquis and Huston (2009, p. 69), not only nursing but all professions require an ethical norm suited to the purpose of that profession. Nursing concerns making people physically as well as possible while emotionally supporting them to enhance the healing process. As such, values and norms exist as a foundation for ethical decision-making, especially where the best possible decision is not immediately obvious. These values therefore provide a valuable starting point for the critical thinking process often required to make the soundest possible decision for the circumstances involved.

If a patient is terminally ill, for example, one major ethical decision concerns whether to grant the person's request for euthanasia or whether the principle of life should be honored above all else. Without ethical and value-based filters to guide such decisions, the profession could become a tool for harm for persons claiming to be in not only physical, but also emotional pain. Ethics is also important when nurses are faced with the limitations of confidential information. In some cases, it is simply not ethically viable to keep information confidential, even if a patient has requested this. In the case of severe illness, for example, a nurse cannot withhold critical information from a person's family members, who will be affected by the illness and the person's need for care.

In all professions where confidentiality is at issue, reasonable-limits clauses tend to be included to protect not only the professional institution, but also the rights of those affected by withheld information. In the legal profession, for example, attorney–client privilege can be withdrawn should the client reveal an intention to continue causing harm to the public. The same is true in the nursing profession. While clients' autonomy and privacy are to be respected, a wider perspective is sometimes required regarding how withheld information can affect a person's loved ones or other interested parties.

According to Goodman (2008, p. 28), problems often arise from the fact that clinicians learn sensitive information from their clients. This information places clients in a vulnerable position, since the clinician now shares that sensitive knowledge. Diagnoses such as cancer or HIV, for example, are among the pieces of information that clients most prefer to keep confidential. There are various reasons for maintaining confidentiality in the nursing profession: if patients do not trust clinicians with their information, they would be unlikely to disclose sensitive details, which could frustrate accurate diagnosis. Clients also prefer to maintain some control over who has access to their information, especially in the case of debilitating conditions such as cancer or schizophrenia.

At its core, the principle of medical confidentiality entails respecting the patient's right to privacy. It also builds trust in the medical profession, which in turn results in greater honesty from patients and more accurate diagnoses. Without this basis of trust, the profession would not be able to accomplish its goals of healing and care.

Confidentiality and Its Reasonable Limits

There are, however, times when reasonable limits must be imposed on the confidentiality clause. If more harm than good results from retaining confidentiality, then limits should be imposed. Absolute confidentiality cannot therefore be guaranteed, and each situation must be assessed individually before decisions regarding confidentiality are made.

It is important to notify patients of the possible need to break confidentiality in certain cases — this is the element of informed consent. Clients need to be made aware of the circumstances under which confidentiality would have to be broken. If there is a reasonable expectation that retaining confidentiality will cause more harm than good, this provides a rationale for overriding the confidentiality code.

If clients are not informed of the limitations of confidentiality, and such confidentiality is then broken, the institution could be liable for legal action. This is why clinicians should carefully explain all elements of confidentiality — and its limitations — to their patients. Patients must at all times be aware of the circumstances under which those limitations come into effect. Medical professionals should therefore be legally required to provide this information before beginning treatment.

Confidentiality should only be broken if a medical professional believes that the client poses a significant risk of harm to him- or herself, or to others. If limitations have not been explained, it may reasonably be assumed that the client expected complete confidentiality. Breaking that assumption under any circumstances would be ethically questionable at best.

In other words, confidentiality should be broken only when there is significant risk, and only when the client has been informed beforehand of the limitations of the confidentiality clause.

There are therefore considerable tensions between the ethical principle of retaining confidentiality under all circumstances and the imposition of limitations on that confidentiality. In order to resolve this conflict in practice, the best approach is to follow a documented ethical viewpoint such as utilitarianism — the principle that the greatest good should result for the greatest number of people involved. This applies specifically to nursing, since it is a profession that places the needs of the client at the top of all priorities. However, if meeting those needs causes harm to others, they can no longer take precedence over the lives or well-being of those others.

Marquis and Huston (2009, p. 71) describe such situations as ethical dilemmas, in which the only choice is between two relatively undesirable options, and where the best choice is inevitably the one that causes the least harm. In the medical profession, this sometimes means breaking confidentiality to serve the greater good.

In the case of Mr. and Mrs. Z, the ethical principle at stake is patient autonomy. Mrs. Z is clearly fully aware of her situation and is capable of making a rational decision regarding disclosure of her condition to her family. To deny her the right to privacy in this matter is to deny her the right to choose whether, and when, to disclose her condition.

On the other hand, one must also consider that Mrs. Z is causing considerable harm — both to her family and to herself — by not disclosing her condition. Treatments are available, and without receiving them she is likely to die, leaving her family without a wife and mother. It is therefore in the best interest of everyone, both ethically and practically, to disclose her condition so that necessary treatment can begin.

An appropriate ethical theory in this case is utilitarianism, or consequentialist theory. According to Marquis and Huston (2009, p. 72), utilitarianism means judging the consequences of an action rather than the ethical considerations that precede it. On this basis, regardless of whether Mrs. Z was initially informed of possible limitations to her privacy, the best outcome for all involved would be to disclose her condition to her family. The needs and wants of the individual then take a secondary position to the common good.

The principle of "need to know," as addressed by DeWolf Bosek (2007, p. 107), could also apply here. The confidentiality clause applies only insofar as there is no need to disclose confidential information to others. In the case of Mrs. Z, her family deserves to know about her situation because it affects their lives directly.

Conclusion

The best possible decision appears to be to attempt convincing Mrs. Z that it is in everybody's interest to disclose her condition and receive treatment. She may need considerable counseling before giving such permission. However, the best possible consequence will follow from her receiving treatment. The professionals involved should therefore do what they can to persuade her of the merits of disclosure, while continuing to respect her dignity and autonomy throughout that process.