2.2 Ethics, Consent & Confidentiality
Key Takeaways
- A competent, informed adult has the autonomous right to refuse or withdraw from any treatment, even life-sustaining care.
- Valid informed consent requires disclosure, capacity, and a voluntary decision, and it is procedure-specific: a significant change to the procedure requires new consent.
- When a client lacks capacity, care follows the provincial substitute decision-maker (SDM) hierarchy and any advance directive, not the nurse's or physician's preference.
- Privacy legislation (PHIPA in Ontario, PIPA/FOIPPA in BC, HIA in Alberta, PIPEDA federally) limits access to personal health information to a legitimate, need-to-know care purpose.
- Curiosity-driven access to the record of a client not in your care is a privacy breach regardless of intent.
Core Ethical Principles
Entry-level practical nursing rests on a small set of ethical principles that the CPNRE and REx-PN test through scenarios:
| Principle | Meaning | Bedside example |
|---|---|---|
| Autonomy | The client's right to self-determination | Honouring a competent client's refusal of chemotherapy |
| Beneficence | Acting to benefit the client | Providing pain relief and comfort |
| Non-maleficence | Avoiding harm ("do no harm") | Withholding an order that appears unsafe until clarified |
| Justice | Fair, equitable treatment and resource use | Assigning care by need, not by favouritism |
| Veracity | Truth-telling | Answering questions honestly rather than giving false reassurance |
| Fidelity | Keeping commitments and promises | Following through on a promised comfort measure |
When two principles collide — for example, a client's autonomy versus the nurse's wish to prevent harm — the exam almost always favours autonomy for a competent client. A useful ethical decision-making framework is: (1) identify the ethical problem, (2) gather the facts and clarify who is affected, (3) identify the relevant principles and the client's own values, (4) consider the options and consult (team, ethics resources, college standards), (5) act, and (6) evaluate the outcome. Notice this mirrors the nursing process and always begins with assessment, not action.
Informed Consent
Informed consent is both an ethical and a legal requirement. To be valid it must have three elements:
- Disclosure — the client is told the nature of the treatment, its expected benefits, material risks, and reasonable alternatives (including no treatment).
- Capacity — the client can understand the information and appreciate the reasonably foreseeable consequences of a decision.
- Voluntariness — the decision is free from coercion or undue pressure.
Consent is procedure-specific. If the nature, scope, or surgical approach of a planned procedure changes significantly, the original consent is no longer valid and new consent must be obtained. Simply rescheduling the same procedure, answering a routine question, or having family present does not require re-consent. A competent client may refuse or withdraw consent at any time, even for life-sustaining treatment; the nurse's role is to use therapeutic communication to explore the reasons, ensure the decision is informed, notify the team, and document — not to argue, moralize, or override the choice.
Capacity and Substitute Decision-Makers
Capacity is decision- and time-specific: a client may be capable of consenting to a simple dressing change but not to complex surgery, and capacity can fluctuate (for example, during delirium). When a client is incapable, the decision passes to a substitute decision-maker (SDM) following the provincial hierarchy. In Ontario the Health Care Consent Act ranks substitutes roughly as: court-appointed guardian, attorney for personal care, representative appointed by the Consent and Capacity Board, spouse/partner, child or parent, siblings, then other relatives. An advance directive (living will) or do-not-resuscitate (DNR) order records the client's own prior wishes and takes priority over what family or staff might prefer. With a valid DNR in place, cardiopulmonary resuscitation (CPR) is not initiated; the nurse provides comfort measures and notifies the team — family permission is not required to withhold resuscitation.
Confidentiality, Privacy and Advocacy
Protecting personal health information (PHI) is a legal duty under privacy legislation: PHIPA (Personal Health Information Protection Act) in Ontario, PIPA and FOIPPA in British Columbia, the Health Information Act (HIA) in Alberta, and PIPEDA federally. The governing rule is need-to-know: a nurse may access a record only when there is a legitimate, care-related reason for a client in their care. Looking up a neighbour's, celebrity's, or non-assigned client's chart out of curiosity is a privacy breach regardless of intent, and may lead to discipline. Confidentiality is not absolute — it yields to mandatory reporting duties (suspected child abuse, certain communicable diseases, or a serious risk of harm), but disclosure is limited to what the law requires.
Advocacy ties these threads together: the nurse provides information and supports the client to participate in decisions, speaks up when care is unsafe, and protects vulnerable clients. Client-centred advocacy means supporting the client's own informed choices, not making decisions for them and not simply deferring to family or the physician.
Worked Example: An Ethical Dilemma
A client with limited English wishes to consent to surgery. Using the client's teenage child to interpret would risk inaccuracy and breach confidentiality; the ethically and legally sound choice is a professional interpreter so that disclosure is accurate and the client's autonomy is genuinely exercised. Apply the framework: identify the problem (is consent truly informed?), gather facts, weigh autonomy and veracity, consult resources (interpreter services), act, and evaluate understanding with a teach-back. The exam consistently favours qualified interpreters over family members for clinical communication.
Cultural Safety and Traps to Avoid
Cultural safety requires humility and respect for a client's values, including Indigenous clients who wish to include traditional healing. The safe response is to acknowledge the wish and collaborate to integrate the practice where it is safe, not to dismiss it as "not evidence-based" or refuse it outright. Watch these traps: a competent client may refuse care even when the family disagrees; confidentiality is not absolute and yields only to mandatory reporting; and false reassurance ("everything will be fine") violates veracity and shuts down therapeutic communication.
An alert, oriented client with cancer states, "I don't want any more chemotherapy. I'm done." What is the nurse's most appropriate response?
Which situation requires a NEW informed consent before proceeding?
A practical nurse looks up the electronic health record of a client who is not assigned to the nurse, purely out of curiosity. This action primarily violates which principle?