by Alexandra Wllson Pecci

A Navy nurse faces possible discharge for refusing to participate in force-feeding detainees. It's a test case for nurses in all practice settings who are faced with ethical issues every day.

Nurses have the right and an obligation to an ethical practice. With it should come the right to speak up without punishment when that ethical practice is threatened.

But possible punishment is exactly what's at stake for a U.S. Navy nurse who refused to continue force-feeding hunger-striking detainees at Guantanamo Bay Detention Camp. Although the Navy has opted not to press criminal charges, it is still considering requiring the nurse to show cause for remaining in the Navy, which could lead to his discharge, the end of an 18-year Naval career, and the possibility of no retirement or veteran's benefits.

Moreover, a discharge would send a "message from the Navy that nurses who refuse to participate in force-feeding could lose their careers," the nurse's attorney, Ron Meister, said during an media call last week led by the American Nurses Association.

The ANA has taken up the fight on behalf of the Navy nurse, who hasn't been publicly identified, arguing that he should be able to refuse to participate in force feedings without punishment.

"Professional registered nurses have the right to make independent ethical judgments, regardless of the setting in which nursing care is provided, even if this causes the nurse to experience conflict arising from competing loyalties," ANA President Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, said during the call.

The other people on the call—Vincent Iacopino, MD, PhD, senior medical advisor for Physicians for Human Rights, and Albert Shimkus, retired Navy captain and associate professor at the U.S. Naval War College—argued not only the rights of the nurse, but also against the unethical practice of force-feeding these patients, who are protesting indefinite detention. Many of these detainees, the experts noted, have been approved for release.

Whether or not force-feeding is ethically unacceptable is only part of what's at stake here.

"In many ways this is a test case," and not just for the military, Cipriano said, but also for nurses in all practice settings who are faced with ethical issues every day.

The need for discussion and guidance around issues like this one was the impetus for the first National Nursing Ethics Summit, held at Johns Hopkins University in August, and a new report that recently came out of that summit, Blueprint for 21st Century Nursing Ethics: Report of the National Nursing Summit.

The case of the Navy nurse "parallels in some ways the very issues that came up in the nursing ethics summit," Cynda Hylton Rushton, PhD, RN, FAAN, the Bunting Professor of Clinical Ethics at the Johns Hopkins School of Nursing and Berman Institute of Bioethics, and lead organizer of the summit, told me last week.

"I think we really need to take seriously these examples," she says.Issues ranging from nurses going on strike to end-of-life care to the decision not to participate in force-feeding are "really are symptoms of this more fundamental issue: Do we actually have a culture where it's safe for nurses to speak up and speak out about their ethical concerns?" she says.

In preparation for the conference, organizers reached out to nurses to find out what keeps them up at night (encapsulated in a video) and heard about issues such as balancing quality and safety with efficiency; navigating respect for patients, especially at end-of-life; balancing the burdens and benefits of technology; and respecting individual patient choices in the context of their culture, religion, and values.

These are all ethical issues; yet Rushton notes that the IOM's Future of Nursing report was "largely silent on the ethical issues, and the roadmap for the future hast to include this ethical dimension."

She says the summit and report represent the first time that multiple stakeholders—collaborating partners include the ANA, American Academy of Nursing, American Association of Critical-Care Nurses, and many other groups—have come together to create its ethics blueprint, which includes recommendations in the following areas:

Clinical practice: Create tools and guidelines for achieving ethical work environments, evaluate their use in practice, and make the results easily accessible.

Education: Develop recommendations for preparing faculty to teach ethics effectively.

Nursing research: Develop metrics that enable ethics research projects to identify common outcomes, including improvements in the quality of care, clinical outcomes, costs, and impacts on staff and the work environment.

Policy: Develop measurement criteria and an evaluation component that could be used to assess workplace culture and moral distress.

"It's one thing to deal with these issues in the theoretical, but when the rubber hits the road is when nurses are confronted with these issues in the moment," Rushton says. That's why it's so critical for nurses to have a strong foundation from which they can raise and act on these ethical concerns without fear of reprisal, as in the case of the Navy nurse. The summit has also sparked an online pledge campaign to support ethical nursing practices.

"Some of the issues we confront we are meant to struggle with. …The values that underlie these issues are fundamental to who we are as people and who we are as a society," Rushton says. "Do we have space for people to request not to participate in actions that they find morally objectionable? There are no easy answers, and that's the point."