To: Ethics Advisory Board   

From: Concerned RN

Subject: Refusal to participate

Two nurses on my unit have submitted written notification stating that they would no longer participate in administering and monitoring blood transfusions for patients, even in emergency situations, based on their religious beliefs. In our department, being on-call is mandatory and part of the job description. The two nurses have been removed from mandatory call to protect patient safety, since either nurse may be the only nurse available if an emergency did occur. Our hospital’s human resources department is deliberating whether to accommodate their request.

I believe it’s unethical for a nurse to refuse to care for a patient in an emergency situation and for a nurse to project their beliefs (refusal to participate in the administration of blood) onto a patient and not honor the patient’s autonomy and desire to be cared for in an emergency. Is my belief supported by the Code of Ethics for Nurses with Interpretive Statements (the Code)? 

From: ANA Center for Ethics and Human Rights

The Code justifies the nurse refusing to participate in any “decision or action that is morally objectionable to the nurse.” But there are limitations.

Lachman states that respect for conscience is similar to the ethical principle of the respect for persons, and that conscience-based refusals are based on an individual’s commitment to his or her moral beliefs. The Code is uncompromising in that conscience-based refusals to participate or perform a responsibility “exclude personal preference, prejudice, bias, convenience, or arbitrariness.” Nurses have an obligation to provide for patient safety and a duty to respect patient autonomy. Any decision made by the nurse not to participate on the grounds of conscientious objection must be explicitly communicated in a timely and appropriate manner. The Code instructs the nurse that “such refusal should be made known as soon as possible in advance and in time for alternate arrangements to be made for patient care.”

By entering the nursing profession, the nurse assumes a professional obligation to place the well-being and rights of patients at the center of professional practice. According to Stahl and Emanuel, “in emergency situations healthcare professionals must provide medically indicated services despite personal objections.” The Code is clear: Nurses are required to keep their patient safe, to avoid abandoning their patient, and to leave their patient only when the nurse is certain that nursing care is available for the patient.

Your unit has decided that the two nurses who refuse to administer blood and monitor a blood transfusion will not take mandatory call. The unit won’t place these nurses in an emergency where their nonparticipation in this procedure places a patient in harm’s way.

The nurses must understand that their refusal may be one of moral courage, but that this refusal doesn’t protect them from formal or informal consequences. Compromises that protect patient safety and preserve the dignity of all nurses concerned can be difficult to achieve. A safe forum with mutual respect, self-reflection, and discovery about why the two nurses feel they must refuse to participate, even in an emergency, may help.

The Code supports the obligation of all nurses to ensure patient safety in every situation.

— Elizabeth Swanson, DNP, MPH, APRN-BC, is a member of the ANA Center for Ethics and Human Rights Advisory Board.