In the midst of an ethical dilemma, have you ever turned to a professional code of ethics? If the answer is no, it comes as no surprise. The purpose, content, and effectiveness of such codes are subjects of continuing debate. Two of the best-known codes in health care, those of the American Medical Association (AMA) and the American Nurses Association (ANA), underwent revision last year. What practical purpose do codes serve? Do they—can they—have an appreciable impact on medical or nursing practice?
Today's codes are all descendants of the ancient, still-influential Hippocratic Oath. Like that oath, these codes not only stress essential norms of professional behavior, but also urge professionals to develop inner qualities—attitudes and virtues—that can shape that behavior. Codes also hold out ideals or aspirations that beckon the practitioner toward continuous professional growth and improvement in practice.
Codes come in various shapes and sizes. The new ANA code features a set of principles, then adds "interpretive statements." The revised AMA code is a composite of principles, a statement of "fundamental elements"—essentially patient rights—in the physician-patient relationship, and opinions on specific ethical questions from the AMA's Council on Ethical and Judicial Affairs.
Codes of ethics differ in the mechanisms by which they hold professionals accountable. Some appeal primarily to the professional's good will through voluntary loyalty to the code's tenets. Others promise to address violations with sanctions ranging from professional reprimand to loss of certification or even revocation of the license to practice. Sanctions signal that, desirable as voluntary conformity is, professionals are morally fallible human beings whose ethical consciousness may need external support.
But do codes of ethics "work"? Do they make professionals more ethical? One answer is, "Not always." Some in Andersen's auditing division or among Enron's executives certainly did not follow the codes promulgated by their respective professional groups. Even doctors and nurses may fail to abide by their professions' codes. Nevertheless, codes can have a variety of positive effects, both on professionals and on professions themselves. By identifying behavioral norms and professional virtues, codes support the development of professional integrity and character. Particular norms establish standards of conduct for practitioners, and in the process help to define the profession itself. Further, a code's delineation of issues helps professionals, new and old, recognize what counts as an ethical concern.
Yet no code is immune to criticism. Codes may state the obvious—of course a practitioner should keep a confidence or respect a client—or be too general to give concrete guidance. When those within the profession formulate the code, they may take a narrow view of what counts as an issue, see the issues through professional-friendly lenses, or fall short on enforcement provisions.
Thus the public wonders: do codes have any real value beyond use as window dressing, a public declaration that this profession and its practitioners take ethics seriously and thus are ethical? At the least, codes serve as a perennial reminder, like religious scriptures, that healthcare professions are a high calling. Professionals exist to serve others, not themselves, and "anything goes" is never acceptable as a professional watchword—especially in health care.
Further, although codes are not designed to provide specific guidance in individual cases, a code of ethics may function as a moral compass, as the following case discussion illustrates.
Mr. R. is a forty-five-year-old man suffering from metastatic cancer. He is weak, short of breath, and in persistent pain. He confides to his nurse that he is ready to die and wants no more life-sustaining treatment. The nurse knows that his wife, on the other hand, expects a miracle. Mrs. R. agrees with the physician, who wants to begin another course of chemotherapy for her husband. The nurse hesitates to take issue with the physician—and Mrs. R.—about the treatment. But she believes no miracle is likely, and she feels she has a responsibility to advocate for her patient.
No code of ethics can anticipate all the particulars of a case. But several provisions of the ANA code seem relevant here. For example, the code states that "the nurse's primary commitment is to the patient." The point may seem obvious, but in a tense situation it can serve as a moral anchor. Second, by recognizing that advocacy for the patient's rights is a professional obligation, the code supports the nurse's inclination to advocate for Mr. R.'s wishes.
The code also holds that "the nurse is responsible and accountable for individual nursing practice." Together with nursing's commitments to the patient's rights and well-being, this provision suggests that the ethical nurse does not simply acquiesce to others' views about how to treat the patient—even when one of those others is the treating physician. She does not make the final treatment decisions, to be sure, but the code would not support an abdication of her professional responsibility—and right—to voice her concerns. Further, by speaking up for the patient's interests and rights as she understands them, she acts consistently with another code provision by promoting a "healthcare environment . . . conducive to the provision of quality health care."
Nursing's fundamental commitment to "respect . . . the inherent dignity, worth and uniqueness of every individual" may also guide the nurse toward a balanced response in this situation. Respect is due the wife and the physician as well as the patient. This obligation may include respect for the possible religious roots of the wife's expectation of a miracle, or for the physician's beneficence-based commitment to aggressive treatment. The nurse may disagree respectfully with a proposed treatment course or gently question the wife's assumptions. But respect suggests a prior attempt to understand another's point of view, an effort to listen and understand nonjudgmentally before responding. The nurse's moral bedrock remains her commitment to the patient; the ANA code opens a wider moral horizon and asks the nursing professional to keep it in view as well.
