Application of the CNA Code of Ethics during a pandemic
“In a global public health emergency, we may find ourselves questioning whether our existing ideas about what is good, right, and just continue to hold true, or whether we need to adjust our ethical beliefs because of the extreme situation we find ourselves in. This can be very unsettling.” Read Nurses’ Ethical Considerations During a Pandemic [PDF, 244.3 KB] to learn about practice issues specific to COVID-19. The paper examines not only new ethical dilemmas, but existing ones that have been brought into fuller view.
Relevant sections of the CNA Code of Ethics
The CNA Code of Ethics (2017) offers content on ethical considerations during a pandemic.
In Appendix B: Applying the Code in Selected Circumstances (pages 38-40), the Code states:
Historically and currently, nurses provide care to those in need, even when providing care puts their own health and life at risk (for example, when they work in war-torn areas, places of poverty, places with poor sanitation, etc.). Nurses also encounter personal risk when providing care for those with a known or unknown communicable or infectious disease. However, disasters and communicable disease outbreaks call for extraordinary effort from all health-care personnel, including nurses. The Code states:
During a natural or human-made disaster, including a communicable disease outbreak, nurses provide care using appropriate safety precautions in accordance with legislation, regulations and guidelines provided by government, regulatory bodies, employers, unions and professional associations. (A9)
A duty to provide care refers to a nurse’s professional obligation to provide persons receiving care with safe, competent, compassionate and ethical care. However, there may be some circumstances in which it is acceptable for a nurse to withdraw from providing care or to refuse to provide care (CRNBC, 2017b; CRNNS, 2014). Unreasonable burden is a concept raised in relation to the duty to provide care and withdrawing from or refusing to provide care. An unreasonable burden may exist when a nurse’s ability to provide safe care and meet professional standards of practice is compromised by unreasonable expectations, lack of resources or ongoing threats to personal and family well-being (CRNBC, 2017b).
The following criteria could be useful for nurses to consider when contemplating providing care in a disaster or communicable disease outbreak:
- the significance of the risk to the person in care if the nurse does not assist;
- whether the nurse’s intervention is directly relevant to preventing harm;
- whether the nurse’s care will probably prevent harm; and
- whether the benefit of the nurse’s intervention outweighs harms the nurse might incur and does not present more than an acceptable risk to the nurse (ANA, 2006).
When demands on the health-care system are excessive, material resources may be in short supply and nurses and other health-care providers may be at risk. Nurses have a right to receive truthful and complete information so they can fulfil their duty to provide care. They have a clear understanding about the obligations and expectations around their role. They must also be supported in meeting their own health needs. Nurses’ employers have a reciprocal duty to protect and support them as well as to provide necessary and sufficient protective equipment and supplies that will “maximally minimize risk” to nurses and other health-care providers. At the same time, nurses use their professional judgment to select and use the appropriate prevention measures; select, in collaboration with the health-care team, the appropriate agency, manufacturer and government guidelines concerning use and fit of personal protective equipment; and advocate for a change when agency, manufacturer or government guidelines do not meet the infection control requirements regarding appropriate use and fit of personal protective equipment (CNO, 2009b).
Nurses carefully consider their professional role, their duty to provide care and other competing obligations to their own health, to family and to friends. In doing so, they understand the steps they might take both in advance of and during an emergency or pandemic situation so that they are prepared for making ethical decisions (CNA, 2008; Thompson, Faith, Gibson, & Upshur, 2006). Value and responsibility statements in the Code support nurses’ reflection and actions.
A. In anticipation of the need for nursing care in a disaster or disease outbreak, nurses:
- work together with nurse colleagues, unions and joint occupational health and safety committees, and others in positions of leadership to develop emergency response practice guidelines using available resources and guidelines from governments, professional associations and regulatory bodies;
- learn about and provide input into the guidelines the region, province or country has established regarding which persons are to receive priority in care (e.g., priority based on greatest need, priority based on the probability of a good outcome, etc.);
- learn how support will be provided for those providing care and carrying the physical and moral burden of care;
- request and receive regular updates about appropriate safety measures nurses might take to protect and prevent themselves from becoming the victim of a disaster or disease;
- assist in developing a fair way to settle conflicts or disputes regarding work exemptions or exemptions from the prophylaxis or vaccination of health-care providers; and
- help develop ways in which appeals or complaints can be handled within the occupational health and safety framework.
B. When in the midst of a disaster or disease outbreak, nurses:
- refer to regulations and guidelines provided by government, regulatory bodies, employers and professional associations;
- help make the fairest decisions possible about the allocation of resources;
- help set priorities in as transparent a manner as possible;
- provide safe, compassionate, competent and ethical care (in disasters, as much as circumstances permit);
- help determine if, when and how nurses may have to decline or withdraw from care; and
- advocate for the least restrictive measures possible when a person’s individual rights must be restricted.