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Ethics in Nursing
THIRD EDITION

Martin Benjamin Joy Curtis

New York Oxford

OXFORD UNIVERSITY PRESS
1992
Oxford University Press
Oxford New York Toronto
Delhi Bombay Calcutta Madras Karachi
Petaling Jaya Singapore Hong Kong Tokyo
Nairobi Dar es Salaam Cape Town
Melbourne Auckland
and associated companies in
Berlin Ibadan

Copyright © 1981, 1986, 1992 by Oxford University Press, Inc.

Published by Oxford University Press, Inc.,
200 Madison Avenue, New York, New York 10016
Oxford is a registered trademark of Oxford University Press.
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise,
without the prior permission of Oxford University Press, Inc.

Library of Congress Cataloging-in-Publication Data

Benjamin, Martin.
Ethics in nursing / Martin Benjamin, Joy Curtis. — 3rd ed.
p. cm. Includes bibliographical references and index.
ISBN 0-19-506747-9.
ISBN 0-19-506748-7
1. Nursing ethics. I, Curtis, Joy. II. Title.
[DNLM: 1. Ethics, Nursing. WY 85 B468e]
RT85.B39 1992 174'.2-dc20 DNLM/DLC
for Library of Congress 91-3785

98765
Printed in the United States of America
on acid-free paper
For our parents
Ruth Hilleary
Julius Hilleary
Dorothy Benjamin (1914-65)
Louis Benjamin
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Preface

The changes in this edition reflect important developments in nursing and

nursing ethics. First, facts, figures, and references have been updated
throughout. Second, two new cases concerning the care of AIDS patients
have been added. The analysis of these cases includes an entirely new section
(in Chapter 3) on the connection between personal risk and professional
obligation, and an additional discussion (in Chapter 5) on the response of
nursing administrators to nurses reluctant to care for AIDS patients. Third,
we have added a new chapter (7) on cost containment, justice, and rationing
in the health care system. As the question of limited resources becomes even
more urgent, the focus of nursing ethics is expanding accordingly. Nurses
have an ethical duty, based on their obligations to individual clients, to be
informed about and participate in ongoing debates about justice and the
allocation of limited resources—including nursing care—in the health care
system. Chapter 7 provides relevant background information, illustrated
through five cases, and develops an ethical framework for assessing propos-
als for allocating health care. Despite these changes and additions, the
principal aim of the book remains the same: to provide practicing and
student nurses with an introduction to the identification and analysis of
ethical issues that reflects both the special perspective of nursing and the
value of systematic philosophical inquiry.
A number of people have contributed to this edition. Students in our
Ethical Issues in Nursing course have provided useful suggestions and
continuing inspiration for updating and improving the book. In addition,
nurses in a number of workshops organized by hospitals, colleges of nurs-
ing, and professional organizations in various parts of the country have
helped us to identify new topics and issues. We have benefited, too, from
Vlll PREFACE

discussions with several colleagues affiliated with Michigan State Univer-

sity's Center for Ethics and the Humanities in the Life Sciences. Special
thanks are due to Howard Brody, Maureen O'Higgins, Leonard Fleck,
Kenneth Howe, Bruce L. Miller, and James Nelson.
We are also grateful to Crystal Lange, director of the Saginaw Valley
State University School of Nursing, for her critical reading of our work-in-
progress, and to Susan Ecklund, whose careful copy editing saved us from a
number of errors and infelicities. For invaluable assistance in proofreading
we are indebted to Bruce Curtis and David Benjamin. Finally, the sugges-
tions, encouragement, and accommodation of editors Jeffrey House and
Henry Krawitz at Oxford University Press were most helpful in preparing
this edition.

East Lansing, Mich. M.B.

February 1991 J.C.
Preface to the First Edition

The aim of this book is to provide practicing and student nurses with an
introduction to the identification and analysis of ethical issues that reflects
both the special perspective of nursing and the value of systematic philoso-
phical inquiry. Discussions of general and theoretical points are, wherever
possible, grounded in and illustrated by their application to specific nursing
situations. The text includes thirty actual cases, which are discussed in some
detail. In addition, Appendix D contains a set of eleven case studies for
further practice in ethical analysis and reasoning.
The book begins with an account of the nature of moral dilemmas and
outlines the philosophical skills and understanding necessary for addressing
them systematically. Next, Chapter 2 provides an introduction to basic
ethical principles and the complex relationships between ethical, legal, and
religious considerations in the nursing context. Then, through a series of ten
case studies, Chapter 3 focuses upon ethical issues involving nurses and
clients. Chapter 4 discusses complications that arise due to the unclear
nature of the relationship between nurses and physicians. In Chapter 5 we
turn to ethical dilemmas involving relationships among nurses. Finally,
Chapter 6 examines the extent to which nurses ought to be concerned with
the nature and direction of institutional and public policy.
Throughout the book our emphasis in discussing individual cases is to
illustrate the application of ethical analysis and reasoning and the impor-
tance of thinking for oneself. Where we come to conclusions on particular
points, therefore, we do not intend readers to accept them without carefully
examining our reasoning. The importance of critically analyzing the reasons
given for various positions applies to our arguments no less than to those of
others. Readers may or may not agree with our analyses of particular cases,
X PREFACE TO THE FIRST EDITION

but if they come to their conclusions by applying some of the methods,

principles, and distinctions that we have stressed, our purpose will have
been fulfilled. As a recent report on The Teaching of Ethics in Higher
Education put it: "The test of the teaching of ethics is not whether students
end by sharing the convictions of their teachers, but whether they have come
to those convictions by means of the use of skills that might have led in
other directions and may do so in the future" (Hastings-on-Hudson, The
Hastings Center, 1980, p. 61).
Unless otherwise noted, all cases presented in the text were obtained from
practicing nurses as part of a 1978 research study on nurses' perceptions of
ethical dilemmas. The study was based upon one-hour, structured, tape-
recorded interviews with a sample of forty practicing baccalaureate-edu-
cated nurses in Michigan's lower peninsula. The distribution of the principal
employment settings of the nurses who participated in the study closely
approximated the percentage distribution of all active registered nurses in
Michigan whose highest degree was in baccalaureate nursing: there were
28 hospital nurses, 5 community health nurses, 3 nursing school faculty,
2 school nurses, 1 nursing home nurse, 1 office nurse, and no private duty,
occupational health, or self-employed nurses. While the cases developed
from these interviews do not raise all possible ethical issues in nursing, they
offer a fair sampling of the ethical dilemmas that frequently recur in nursing
practice. Names and places have been changed to insure confidentiality but,
wherever possible, the nurses' actual words have been retained.
We want to express our gratitude to the nurses who participated in this
study as well as to a number of others who helped us in preparing this book.
Isabelle K. Payne, Dean of the College of Nursing at Michigan State
University, and Suzanne Brouse, Maureen Chojnacki, Marilyn Rothert, and
Linda Beth Tiedje read the manuscript and made suggestions about the
nursing aspects. Lewis Zerby and Thomas Tomlinson, of the Department of
Philosophy, suggested helpful changes with regard to the philosophical
aspects. Linda Henlotter, a graduate assistant in the College of Nursing,
helped conduct the interviews of practicing nurses, and Stanley Werne, a
graduate assistant in the Department of Philosophy, helped compile the list
of further readings and made suggestions about the manuscript. Though
they are too numerous to mention by name, we also want to express our
thanks to students in our team-taught course in Ethics in Nursing who
helped us evaluate the clarity and relevance of the manuscript and encour-
aged us to complete it.
We are grateful, too, to Michigan State University for an M.S.U. Founda-
tion Grant, which supported the survey of nurses, and an All-University Re-
search Grant, which helped in the preparation of the manuscript. Finally,
thanks are due to three people who provided special assistance. JoAnn
Wittick, of the Medical Humanities Program, cheerfully and skillfully typed
PREFACE TO THE FIRST EDITION XI

the manuscript. Bruce Curtis, of the Department of American Thought and

Language, made line by line stylistic improvements. And Jeffrey House, of
Oxford University Press, offered detailed criticisms and useful suggestions
which helped us strengthen some of our arguments and made certain sec-
tions clearer and more concise.

East Lansing, Mich. M.B.

January 1981 J.C.
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Contents

Cases, xv

1. Moral Dilemmas and Ethical Inquiry

1. Moral dilemmas in nursing, 3
2. Ethical codes: uses and limitations, 6
3. The fundamental question of morality, 10
4. Ethical inquiry, 11
5. Ethical autonomy and institutional-hierarchical constraints, 21
2. Unavoidable Topics in Ethical Theory
1. Introduction, 26
2. Basic ethical principles, 27
3. Knowledge in ethics, 36
4. Ethics, law, and religion, 44
3. Nurses and Clients
1. Introduction, 52
2. Parentalism, 54
3. Deception, 63
4. Confidentiality, 72
5. Personal risks and professional obligations, 77
6. Conflicting claims, 80
4. Recurring Ethical Issues in Nurse-Physician Relationships
1. Conflicts between nurse and physician, 87
2. Nurse autonomy, 97
3. Collaboration, 108
4. Integrity-preserving compromise, 112
5. Conscientious refusal, 116
6. Determining responsibility, 123
XIV CONTENTS

5. Ethical Dilemmas Among Nurses

1. Tensions between nurses, 131
2. Respect for persons, 138
3. Professional obligations, 141
4. Administrative dilemmas, 149
6. Personal Responsibility for Institutional and Public Policy
1. The scope of individual responsibility, 159
2. Institutional policies and strikes, 163
3. Institutional ethics committees, 170
4. Blowing the whistle, 174
5. Public policy: advance directives, 180
6. Putting it all together, 182
7. Cost Containment, Justice, and Rationing
1. Introduction, 188
2. Cost containment and the claims of justice, 190
3. Access to care, 195
4. The concept of rationing, 197
5. The Oregon proposal, 199
6. Toward ethical rationing, 203
7. Rationing and the importance of nursing care, 209
8. The expanding scope of nursing ethics, 210

APPENDIX A
International Council of Nurses Code for Nurses, 216
APPENDIX B
American Nurses' Association Code for Nurses, 218
APPENDIX C
American Hospital Association: A Patient's Bill of Rights, 221
APPENDIX D
Cases for Analysis, 224
Suggestions for Further Reading, 235
Index, 241
Cases

1.1 Withholding the prognosis, 3

2.1 Priorities: baby or parents?, 27
2.2 Religious and legal considerations in conflict, 44
3.1 A helpful lie?, 53
3.2 Parentalistic restraint, 55
3.3 Convincing the patient, 59
3.4 Breaking the cigarette habit, 60
3.5 Promoting a healthy lifestyle, 62
3.6 Giving placebos, 68
3.7 "You won't feel a thing", 70
3.8 Deciding how much to tell, 71
3.9 "I don't want anybody to know", 73
3.10 Confidential information: HIV test results, 75
3.11 Refusal to care for an AIDS patient, 77
3.12 Who is the client?, 80
3.13 A dvocate for parents and children, 82
4.1 The doctor won't come, 87
4.2 Orders not to teach, 93
4.3 Disagreement with a feeding order, 97
4.4 Is it right?, 102
4.5 Giving information to clients, 106
4.6 Should treatment be stopped?, 108
4.7 Emergency room, 116
4.8 Amniocentesis to determine sex, 117
4.9 Disagreeing with a full code order, 120
4.10 Treatment of urinary tract infection, 123
5.1 Medication cover-up, 131
5.2 Judgmental comments, 138
XVI CASES

5.3 Working extra hours, 141

5.4 A question of friendship, 145
5.5 A nurse with a drug problem, 149
5.6 Working in a bureaucracy: special favors, 151
6.1 Short-staffed in ICU, 159
6.2 Suggestion for a strike, 164
6.3 Withdrawing food and fluids, 171
6.4 "MD suspended from operating room", 175
6.5 Hospital and public policy versus patient's wishes, 180
6.6 What would you do?, 183
7.1 Ideals and reality, 188
7.2 Limiting health care, 190
7.3 Prenatal care on the critical list, 195
7.4 Unfortunate but not unfair?, 204
7.5 Ending life support against the family's wishes, 211
A.I Refusing the researcher, 224
A.2 Summer job, 225
A.3 Too many medicines, 225
A.4 Birth control pills, 226
A.5 Sit-down strike, 221
A.6 Failure to comply, 228
A.7 Removal of tracheostomy tubes, 229
A.8 A nurse's suggestion is rejected, 229
A.9 A request to be excused, 230
A. 10 Refusal to begin a research procedure, 230
A. 11 Confidentiality and an attempted suicide, 231
A. 12 Candor and hope, 232
A. 13 Who should pay?, 232
A. 14 Strike vote, 233
A. 15 Who gets a transplant?, 234
Ethics in Nursing