The concept of autonomy appears in all ancient writings and early Greek philosophy. In health care, autonomy can be viewed as the freedom to make decisions about one’s own body without the coercion or interference of others. Autonomy is a freedom of choice or a self-determination that is a basic human right. It can be experienced in all human life events. Involving the patient and family in decision making is also an indication of respect and family-centered care.5

The critical care nurse is often “caught in the middle” in ethical situations, and promoting autonomous decision making is one of those situations. As the nurse works closely with patients and families to promote autonomous decision making, another crucial element becomes clear. Patients and families must have all the information about a particular situation before they can make a decision that is best for them. They not only should be given all the pertinent information and facts but also must have a clear understanding of what was presented.⁶ In this situation the nurse assumes one of the most important roles of the health care team, that is, as patient advocate, providing more information as needed, clarifying points, reinforcing information, and providing support during the decision-making process.

Veracity, or truth telling, is an important ethical principle that underlies the nurse-patient relationship. Communication trust, or the trust of disclosure, is rooted in respect and based on veracity.7

Veracity is important when soliciting informed consent because the patient needs to be aware of all potential risks of and benefits to be derived from specific treatments or alternative therapies.^8–10 Again, the critical care nurse may be in the middle of a situation where all the facts and information about a particular treatment option are not disclosed. Sometimes information has been given accurately to the patient and family but has been delivered with bias or in a misleading way. Veracity must guide all areas of practice for the nurse, that is, in colleague relationships and employee relationships, as well as in the nurse-patient relationship.

Fidelity, or faithfulness and promise keeping to patients, is also a sine qua non for nursing. It forms a bond between individuals and is the basis of all relationships, both professional and personal. Regardless of the amount of autonomy that patients have in the critical care areas, they still depend on the nurse for many types of physical care and emotional support. A trusting relationship that establishes and maintains an open atmosphere is positive for all involved.11 Making a promise to a patient is voluntary for the nurse, whereas having respect for a patient’s decision making is a moral obligation.¹²

Fidelity extends to the family of the critical care patient. When a promise is made to the family that they will be called if an emergency arises or that they will be informed of any other special events concerning the patient, the nurse must make every effort to follow through on the promise. Fidelity not only will uphold the nurse-family relationship but also will reflect positively on the nursing profession as a whole and on the institution where the nurse is employed.

Confidentiality is one element of fidelity that is based on traditional health care professional ethics. Confidentiality is described as a right whereby patient information can be shared only with those involved in the care of the patient. An exception to this guideline might be when the welfare of others will be put at risk by keeping patient information confidential. Again in this situation, the nurse must balance ethical principles and weigh risks with benefits. Special circumstances, such as the existence of mandatory reporting laws, will guide the nurse in certain situations.

Privacy also has been described as being inherent in the principle of fidelity. Privacy may be closely aligned with confidentiality of patient information and a patient’s right to privacy of his or her person, such as maintaining privacy for the patient by pulling the curtains around the bed or making sure that the patient is adequately covered.

The principle of justice is often used synonymously with the concept of allocation of scarce resources. With escalating health care costs, expanded technologies, an aging population with their own special health care needs, and in some cases a scarcity of health care personnel, the question of how to allocate health care becomes even more complex. With the recent passage of landmark legislation that will lead to major changes in health care, numerous questions are presently unanswered about the impact on our citizens.13

The application of the justice principle in health care is concerned primarily with divided or portioned allocation of goods and services, which is termed distributive justice. As health care resources become increasingly scarce, allocation of resources to certain programs and rationing of resources within certain programs will become more evident.

The American Nurses Association (ANA) provides the major source of ethical guidance for the nursing profession. The Code of Ethics for Nurses serves as the basis for nurses in analyzing ethical issues and decision making (Box 2-3).²¹

In general, ethical cases are not always clear-cut or “black and white.” The most common ethical dilemmas encountered in critical care are forgoing treatment and allocating the scarce resources of critical care. Before the application of any decision model is made, it must be determined whether a true ethical dilemma exists. Thompson and Thompson22 delineate the following three criteria for defining moral and ethical dilemmas in clinical practice:

One must pause, expand group consciousness about the issue, validate assumptions, look for patterns of thoughts or behaviors, and facilitate reflection and inquiry prior to making any decision.²³

To facilitate the ethical decision-making process, a model or framework must be used so that all parties involved will consistently and clearly examine the multiple ethical issues that arise in critical care. There are various ethical decision-making models in the literature.24,25 Box 2-4 lists steps in a model that will be briefly discussed in this chapter.