• Reflect on your own value system. What principle in
the code that covers your country is the most mean-
ingful to you?
• Is there a value you believe is important for you that
is not captured in the International, Australian or New
Zealand codes?
Now think about these questions:
• Which ethical principles are involved in assessment of
clinical practice standards?
• How might the assessee’s moral judgement be taken
into account in the assessment decision?
• How might the underlying power structure inherent in
the assessor/assessee relationship contribute to the
assessment outcome? Should this be taken into
account when making the assessment decision?
Patients’ rights
The principle-based approach to bioethics identifies auton-
omy as the first principle in a list of four (Beauchamp &
Childress, 2009), acknowledging the individual’s right to
make choices based on personal values and beliefs. The
rights of the individual to question the quality of their
healthcare, and to have their personal views and beliefs
about their health taken into account during the planning of
their care, are supported in Australia by the Australian
Charter of Healthcare Rights, developed by the Australian
Commission on Safety and Quality in Health Care
(ACSQHC, 2012). This charter sets out the following rights
for patients in the Australian health system:
•
Access to healthcare
•
Safe, high-quality treatment
•
Respect, dignity and consideration
•
To be informed about services, treatment, options and
costs
•
To be included in decisions and choices about care
•
To privacy and confidentiality
•
To comment on care and have concerns addressed.
Similar patient charters have been developed by state and
territory governments (e.g. Patients’ Charter of Rights,
Queensland Health, 2002). They are regularly audited for
compliance through quality accrediting bodies such as the
Australian Council of Healthcare Standards (ACHS). With
care moving increasingly from the hospital to the commu-
nity, nurses and midwives must be familiar with how
different institutions and professional groups define patient
rights and responsibilities.
New Zealand also has a system dedicated to the preserva-
tion and monitoring of patient rights. The
Health and
Disability Commissioner Act 1994
of New Zealand created
the Office of the Health and Disability Commissioner,
whose role is to promote and protect the rights of health and
disability consumers. The office is also charged with the res-
olution of complaints in a fair and timely manner. A national
network of advocates implements the services under the
Director of Advocacy and an independent prosecutor, the
Unit II Foundations of nursing and midwifery practice
202
Director of Proceedings. The Code of Health and Disability
Services Consumers’ Rights sets out ten rights, which
include the right to be treated with respect, to be free from
discrimination or exploitation, to dignity and independence,
to services of an appropriate standard, to give informed
consent, and to complain (Health and Disability Commis-
sioner, 2009; Parliamentary Counsel Office, 2004).
Often the ethical issue involved in a patient’s rights is not
immediately obvious because it might be due to an omission
rather than to something someone does or says. Consider
this point in the following scenario.
Rebecca Wright, a 48-year-old woman who has just
recently undergone extensive surgery to treat uterine
cancer, is experiencing several serious postoperative
complications. She states: ‘I don’t know why all of these
things are happening. I ask the doctors. So does my
family. But we get no answers. We just want to know
what is happening.’ The nurse is surprised to observe
that not only does the surgeon not answer Rebecca’s
questions, but that he also dismisses her fears without
any explanation. The nurse would likely feel that the
surgeon and medical team are not being faithful to their
responsibility to address the patient’s questions and
fears. Unless the nurse can effectively advocate for
Rebecca with the medical team, her own ability to be
faithful to Rebecca and accountable for her well-being
will be compromised.
In this scenario the ethical issue is situated in an omis-
sion. What patient right was contravened in this situation?
How could you use your knowledge of patients’ rights to
ensure the questions from Rebecca Wright and those of
her family are acknowledged by the treating doctor
and answered appropriately?
ETHICAL DECISION MAKING
Two types of ethical problems commonly faced by nurses
and midwives are ethical dilemmas and ethical distress. In
an ethical dilemma, two (or more) clear moral principles
apply but support mutually inconsistent courses of action.
Ethical distress
occurs when you know the right thing to do
but either personal or institutional factors make it difficult to
follow the correct course of action. You need sound analyti-
cal skills and the ability to engage in ethical reasoning to
resolve ethical dilemmas and ethical distress. Resources for
ethical decision making are highlighted in Box 11-4.
Making ethical decisions
Every nurse and midwife needs to be confident in using a
process of ethical decision making. Using the process of
person-centred care to make ethical decisions involves fol-
lowing the steps discussed below. The accompanying care
study illustrates this model of ethical decision making
(Box 11-5).
