Sexual and Reproductive Health Advocacy

FAQ - Nurses Working in States with Restrictive Laws

• If I choose to act against the legal requirements, what are some of the consequences I should consider? (13)
• As a nurse, what are my ethical obligations when a law prevents me from providing care that is medically indicated? (11)
• What guidance is offered by the ANA Code for nurses when their ethical practice may conflict with laws and regulations? (11)
• What does is a conscience-based refusal?
• What are my ethical obligations if a law requires me to report my patient who presents with an abortion? (12)
  
  

Q: If I choose to act against the legal requirements, what are some of the consequences I should consider? (13)

A: Nurses cannot access their privilege of a conscience-based objection in the face of legal mandates. If a nurse decides to participate in caring for their patient and is practicing in a state with restrictive laws or regulatory directives where they must deny a patient care and/or report the patient to authorities, there may be consequences including loss of employment, sanctions on individual nursing licensure, and in some states, criminal penalties (including potentially probation or imprisonment). Nurses are accountable for their practice and must be aware of the state laws where they are practicing. While the Code states that “Nurses must not engage in practices prohibited by law....” this assumes the law is ethically supportable (Page 16, 4.3). Despite this, nurses could face legal repercussions for engaging in these practices such as abortion, dilatation and curettage for miscarriage or ectopic pregnancy. However, disregarding a law that mandates you report a patient or parent for engaging in criminalized care is consistent with the Code, as the mandate to report in this case is not focused on the benefit to the patient’s health and well-being.

American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: https://www.nursingworld.org/coe-view-only

Q: As a nurse, what are my ethical obligations when a law prevents me from providing care that is medically indicated? (11)

A: The nurse-patient relationship is the foundation of nursing ethics. The Code of Ethics for Nurses with Interpretive Statements (2015) is clear: the nurse’s primary responsibility is to practice with compassion and respect and recognize the dignity and uniqueness of each individual. The Code states that the nurse’s primary commitment is to their patient, whether an individual or family. Nurses have an ethical obligation to their patients in assisting their health and well-being. Nurses hold respect for patient rights as paramount. In states that criminalize medically indicated healthcare, nurses must weigh the consequences of not abiding by the law or abiding by the law, despite its immorality. Nurses should work together with clinical peers and leaders to develop a consensus on how to navigate these new laws while keeping the patient at the forefront. Nurses must understand that actions not in compliance with the law, even if medically indicated, come with legal risk.  

American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: https://www.nursingworld.org/coe-view-only

Q: What guidance is offered by the ANA Code for nurses when their ethical practice may conflict with laws and regulations? (11)

A: Choosing between ethical practice and complying with legal requirements will prove to be extremely challenging for many nurses, particularly given the divergence in state policies and how they are applied at the institutional level. ANA recognizes the uncertainty that can arise when nurses must weigh their ethical obligation to support medically indicated healthcare against the legal consequences they can incur as a result.  The Code outlines, “Practice standards must be developed by nurses and grounded in nursing’s ethical commitments and developing body of knowledge. These standards must also reflect nursing’s responsibility to society” (ANA, 2015, p. 28). However, when laws or legal obligations conflict with ethical norms and expectations of practice, nurses should consider the following recommendations informed by the Code:

• Uphold the profession’s central tenet of respect for human dignity and human rights.
• Know and understand the laws and regulations of your state.
• Advocate for patient preferences and choices when care processes and decisions do not appear to be in the best interest of the patient (Scope and Standard p. 95). This can take place across the spectrum – at the bedside, in the community, or in the boardroom.
• Bring forward difficult issues related to patient care and/or institutional constraints upon ethical practice for discussion and review (p. 32)

American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: https://www.nursingworld.org/coe-view-only

American Nurses Association. (2021). Nursing Scope and Standards of Practice. Silver Spring, MD.

Q: What does is a conscience-based refusal?

A: Interpretive Statement 1.2 of the Code of Ethics for Nurses notes that “respect for patient decisions does not require that the nurse agree with or support all patient choices” (p. 1), thus the nurse is not required to compromise his or her integrity in the provision of such care. Such situations may result in the nurse experiencing moral distress. “When a particular decision or action is morally objectionable to the nurse, whether intrinsically so or because it may jeopardize a specific patient, family, community, or population, or when it may jeopardize nursing practice, the nurse is justified in refusing to participate on moral grounds. Conscience-based refusals to participate exclude personal preference, prejudice, bias, convenience, or arbitrariness” (ANA, 2015a, p. 21). In no instance should a nurse refuse to treat a patient based on that patient’s individual attributes; such treatment violates one of the central tenets of the professional Code of Ethics for Nurses.

A well-established ethical commitment when declining to provide care on moral grounds is the primacy of patient care. “Nurses are obliged to provide for patient safety, to avoid patient abandonment, and to withdraw only when assured that nursing care is available to the patient” (ANA, 2015a, p. 21). If a nurse feels that a moral or ethical consideration prevents him or her from delivering health care services, then the nurse, the full medical team, and/or the practice, institution, health system, or agency, should make an exhaustive and good-faith effort to ensure that the patient easily receives those health care services. Discrimination in health care settings remains a grave and widespread problem for many vulnerable populations and contributes to a wide range of health disparities.

American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: https://www.nursingworld.org/coe-view-only

Q: What are my ethical obligations if a law requires me to report my patient who presents with an abortion? (12)

A: If a state should require nurses to report patients who seek abortion, nurses must first assess the physical and mental well-being of their patient.  Then, the nurse should consider the state’s legal consequences if they choose to disregard the law and not report their patient. While the law in that state may require the nurse to report, it is ethically justified for the nurse to protect the privacy and confidentiality of the patient seeking care. Nurses may find themselves in situations in which they must choose to uphold the ethical constructs of the profession despite their state and/or institution’s lack of support or agreement. In these situations, the nurse understands either decision holds real consequences for the patient and the nurse.