J7ournal of medical ethics, I977, 3, 115-123

Royal College of Nursing (Rcn) code of professionalconduct: A discussion document

We are printing in its entirety the discussion document which sets out a code ofprofessional conductfornurses published by the Royal College of Nursing in November I976 together with commentaries by theAssistant Secretary of the British Medical Association, a professor of nursing studies, student nurses and alawyer.

The image of the nurse is still that of one of Florence Nightingale's young ladies or of a member of areligious order who is wholly dedicated to caringfor the sick. Today, as this document and the commentsupon it show, 'dedication' is still part of the motive which leads a man or woman to become a nurse but inaddition, and this is where the public may be ignorant or choose to be ignorant, nursing offers a careerwhere intellectual achievement and the satisfaction of a demanding job bring their properfinancial rewardand place in the professional cormnunity.We are grateful to the Royal College of Nursingfor permission to publish this document.

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I INTRODUCTIONThe profession of nursing has a commitment whichis shared with other health care professions to pro-mote optimal standards of health, combat diseaseand disability and alleviate suffering. A code ofprofessional conduct is required in order to makeexplicit those moral standards which should guideprofessional decisions in these matters, and in orderto encourage responsible moral decision makingthroughout the profession. It is recognized that nocode can do justice to every individual case andtherefore that any set of principles must remainconstantly open to discussion both within thenursing profession and outside it.

DiscussionI The starting point of this code is the recognitionthat nursing is now a profession in its own right,with all the responsibility which that entails. Itshares with other professions - notably medicineand social work - the goal of improving the healthprospects of all members of that society whichgrants it the right to practice. Because ideas abouthealth goals vary from individual to individual, andbecause nurses have considerable influence (and onoccasion power) over patients or clients whose needsand handicap often render them especially vulner-able, a code of conduct is needed to provideguidelines for professional practice. Such a codeought to be continuously developed and refined bysustained discussion among nurses themselves, andby consultation between nurses and those who canspeak for other professions and for the generalpublic.Codes are never a substitute for personal moral

integrity, and they can often be hardened into legalformulae. It must therefore be stressed that thepurpose of this code is not to devise grounds fordisciplinary proceedings (or any similar purpose),but rather to provide a clear and comprehensivedocument for further discussion, particularly duringperiods of professional training.

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II RESPONSIBILITY TO PATIENTS OR CLIENTSThe primary responsibility of nurses is to protectand enhance the wellbeing and dignity of eachindividual person in their care. As members ofprofessional teams nurses should recognize andaccept responsibility for the total effects of nursingand medical care on individuals. This responsibilityis in no way affected by the type of origin of theperson's need or illness or by his age, sex, mentalstatus, social class, ethnic origins, nationality orpersonal beliefs. Therefore it follows that:

I) Nursing care should be directed towards thepreservation, or restoration, as far as is possible, ofa person's ability to function normally and indepen-dently within his own chosen environment.

2) Discrimination against particular individuals,for whatever reason, should never be tolerated.

3) During episodes of illness the autonomy ofpatients should be maintained throughout treatment,restrictions being imposed only when these aredemonstrably necessary for their own wellbeing, orfor the safety of others; and the active participationof patients in their own treatment should befacilitated by means of open and sensitive com-munication.

i) As a form of social occupation nursing servesseveral ends: it provides paid employment to a largesection of society; it gives individuals a sense ofintellectual achievement and job satisfaction; and itoffers congenial and rewarding inter- and intra-professional relationships. But none of these shouldtake precedence over the primary end of nursing,which is to enable people to live their own lives asfully and freely as possible by providing professionalcounsel and care according to particular needs.

2) Entering the nursing profession involves acommitment to the service of persons, each ofwhommerits individual respect. At times nurses may haveprejudices against patients or clients because theyconsider that they are largely responsible for theirown misfortune or because they cannot feel anysympathy for their particular form of distress. Butthe adoption of a professional attitude requires thatall those who need nursing care should receive itwithout discrimination. No group of patients orclients should be regarded as unworthy or undeserv-ing of professional concern.

3) Nurses share in responsibility for the effect ofthe multidisciplinary treatment methods of modernmedicine on personal health and freedom. Inparticular, the routines of hospitals and healthinstitutions and other organizational structures mayunnecessarily remove the dignity and independenceof patients, thereby diminishing their overall healthprospects. In view of this a fundamental aspect ofthe nurse's responsibility to the patient can be seenas the maintenance and restoration of personalautonomy. This is principally achieved by skillednursing care of each individual, with an under-standing of the context of his illness or disabilityand with careful attention being paid to conmuni-cation with him, especially during periods ofanxiety. In this context it should be noted that thebest source of information about the patient isusually the patient himself and that regular andrelaxed discussions with relatives can increase thenurse's understanding of the patient's circumstancesand of possible ways in which he can be helped toachieve an optimal level of living. It is recognizedthat dealing with violent or potentially violent

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patients raises particularly difficult problems inrelation to restraint and patients' freedom. It isessential that clear guidelines are given to all thosewho have such patients in their care to ensure thatprejudice and mutual fear between patients andstaff do not worsen the situation (see the guidelinesoffered by the DHSS on the basis of joint advicefrom the Rcn and the Royal College of Psychiatrists- The Management of Violent or Potentially ViolentHospital Patients. HC(76)I I).

4) Measures which jeopardise the safety ofpatients, such as unnecessary treatments, hazardousexperimental procedures and the withdrawal ofprofessional services during employment disputes,should be actively opposed by the profession as awhole.

5) Information about patients or clients shouldbe treated with the utmost confidence and respect,and should not be divulged to persons outwith theprimary care or treatment team without the person'sconsent, except in exceptional circumstances.

III RESPONSIBILITY FOR PROFESSIONAL STANDARDSThe professional authority of nurses is based upontheir training and experience in day-to-day care ofill persons at home or in hospital; and in theenhancement of positive health in the communityat large. All members of the nursing profession havea responsibility to continue to develop their know-ledge and skill in these matters.

4) Actions which betray people's confidence inthe professional integrity of nurses diminish theability of the profession to be of help. For thisreason the nursing profession should be clearly seento be opposed to exploitation of vulnerability: forexample, treatment and experimentation, inappro-priate treatment, risky experimentation or experi-mentation without proper consent; or industrialaction, the removal of professional services whichput patients at risk.Although choice of treatments and the initiation

of clinical research projects is usually solely a medicalresponsibility, nurses have the right and the duty toexpress opinions about the effect of such procedureson the patients under their care. (For instance, anurse may question whether the dignity of a dyingpatient is being respected by procedures employedto delay death; and the design of an experimentinvolving discomfort or risk to patients may bequestioned by nurses asked to cooperate in theexperiment.)

Nurses are entitled to equitable wages and con-ditions of employment and should be free to enterinto appropriate negotiations with their employers.But since seriously ill people are in no position toprotect themselves when professional aid is with-drawn, disruption of services by strike action andthreats to do so contravene the nurse's commitmentto service ofpatients and should be publicly opposed,whether the action is carried out by nurses or byother professions and occupations involved inhealth care.

5) In unusual circumstances it may be necessaryto disclose confidential information for the wellbeingof the patient or others in the nurse's care, but thisshould never be done without full consultation withrelatives and with medical and nursing colleagues;and whenever possible the patient should be toldwhy such a disclosure was felt to be necessary.

III The claim to professional status implies thatnurses have particular forms of knowledge and skillin health care which are not shared by other pro-fessions and which thereby give them the authorityto institute nursing procedures and make decisionsand recommendations about correct nursing care.

This claim must be substantiated by the pro-fession as a whole through the establishment of

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IV RESPONSIBILITY TO COLLEAGUESIn general, relationships with colleagues in nursingand in other health care professions should bedetermined according to what will maximize thebenefit of those in their care.

I) Professional relationships between nursesshould be regulated according to the level of know-ledge, experience and skill of each nurse. Clearchains of command should be established to dealwith emergency situations, but except in suchsituations, free discussion of the reasons forestablished procedures should be encouraged at alllevels.

2) Professional relationships between nurses anddoctors should be regulated according to theparticular expertise of each profession. In the caseof medical treatments nurses are under an obligationto carry out a doctor's instructions except where theyhave a good reason to believe that harm will becaused to the patient by so doing. In cases in whichnurses' continuous contact with the patient hasgiven them a different insight into the patient'smedical- needs, they are under moral obligation tocommunicate this to the doctor in charge of thecase. Nurses should support the multidisciplinarycase-conference approach to treatment decisions,and should improve their ability to participateactively in such conferences.

3) Professional relationships between nurses andmembers of other health care professions should bebased upon respect for each other's area of expertiseand on the desire to gain a fuller understanding ofthe patient's or client's needs. Procedures should beestablished for regular inter-professional consulta-tions.

ining procedures and the maintenance of com-petence at all levels within the profession and bycontinued research into new and improved methodsof nursing care.

Individual nurses have the responsibility to beself-critical of their professional performance and toseek to adapt it to changing needs and new tech-niques of care.

IV The goal of 'whole person treatment' determineshow nurses should relate professionally to theirfellow nurses and to members of other health careprofessions. It is assumed that the more there iscooperation and communication between thedifferent people caring for the patient, the more thepatient's needs are likely to be understood andcatered for. (As noted in the previous section, thepatient himself has also a great deal to contribute tosuch full understanding, as do his relatives.)

i) The nursing 'hierarchy' can be seen to benecessary to ensure that decisions are taken by thosewho should have the requisite knowledge andexperience, but on the other hand junior membersof staff can often bring fresh insights about patientsor be more successful in gaining the patient'sconfidence. For this reason an atmosphere offriendly questioning and discussion between staff atdifferent levels can improve the quality of care aswell as making nurse education more effective.(Obviously clear lines of authority are needed forsituations in which rapid decisions have to be made.)

2) Nurses are not trained to diagnose illness or toprescribe medical treatment. They must thereforenormally carry out doctors' instructions in thesematters and help maintain the patient's confidencein his medical advisors. But nurses are in a uniqueposition to observe the condition of the patient atall hours of day and night and have received basicinstruction in drug dosages, effects of treatment, etc.For this reason they are morally obliged to questionmedical instructions which they believe will causethe patient harn or unnecessary distress (see sectionII) even though they may fear adverse effects ontheir career from doing so. Ideally, however, thisshould not entail a confrontation between doctorand nurse, but should arise naturally in the contextof ongoing inter-professional discussions in caseconferences. Part of the professional training ofnurses should prepare them to take part in suchconferences from their own professional standpoint.

3) In the case of other professions which mayhave contact with patients or clients (eg, paramedicalprofessions, social workers, hospital chaplains andother clergy) nurses should be concerned to establishrelationships of trust. This should promote a mutualunderstading of professional roles enabling thepatient/client to derive mum benefit from thework of the caring team.

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V PROFESSIONAL RESPONSIBILITY AND PERSONALRESPONSIBILITYAs citizens of a state and as private individualsnurses should defend and actively pursue thosemoral values to which their profession is committed,namely, individual autonomy, parity of treatmentand the pursuit of health. In some circumstancesthis may require protest against, and opposition to,social and political conditions which are detrimentalto human wellbeing; and in others, the altering ofpersonal habits which set a poor example in healthcare. In all other respects nurses have the right toregulate their private lives according to their ownstandards of morality, provided their style of lifedoes not cast doubts on the integrity and trust-worthiness of their profession.

V Because nursing finds its origins partly in religiousorders, there may be unrealistic expectations bothwithin the profession and among the general publicabout the degree of personal dedication to whichmodem nurses should aspire. Like other profes-sionals, nurses have the right to conduct theirprivate lives without undue interference fromcolleagues or employers. Also like other profes-sionals, however, the choice of a personal servicecareer commits the nurse to certain moral views.Nurses cannot strive to alleviate disease and suffer-ing without becoming aware of the social circum-stances which bring it about or which inhibit theprovision of effective remedies. It follows thatnurses should be concerned with political and socialissues, whenever these are relevant to the preventionof disease or the delivery of health care. Similarlyin the sphere of personal conduct, nurses shouldstrive to 'practise what they preach' to avoidpersonal habits which are known to be detrimentalto health. (For example, doctors and nurses areparticularly at risk for drug and alcohol addiction -a factor which seems to demand closer supportiveattention from their respective professions.)

In addition to setting a good example in healthystyles of life, nurses need to inspire confidence inpatients in order to be able to help them fully. Thisdoes not imply 'angelic' purity of life - merely thefollowing of standards of honesty and of moralseriousness which would be expected from anymember of society who has responsibility for thewelfare of others.

Commentary

J D Dawson British Medical Association,Tavistock Square, London

Origins of ethical codes

In the climate of opinion in which we find ourselvesat the moment I suppose it was inevitable that thereshould appear from the Royal College of Nursinga discussion document setting out a code of pro-fessional conduct for nurses. The text of the code,and the associated discussion have a number ofinteresting facets but before examining the code indetail I think it may be useful to look briefly at theorigins of ethical codes in general.

GENERAL PREMISESStructure and organization in some form is a premiseof any society and the majority of individualswithin a society recognize that the rights conferredand duties exacted by social institutions are mutual.In other words, a major reason for the success of asociety is the individual's awareness that it is to his

ultimate advantage to comply with the requirementsof that society.Moral codes are like other demands made upon

members of a social organization and it is importantto recognize that these demands will change withthe changing conditions that the organizationexperiences. The ethical principles of the group willlie within certain universal prohibitions and require-ments but are secondary to the established behaviourof the group. The importance of the latter pointcannot be overemphasized; ethical principles andrules have no independent existence of their own,they occur subsequently to experience and arecrystallized out of established patterns of behaviour.

Ethical codes that have evolved from the experi-ences of a society or a group of people invariablycontain sanctions against individuals whose be-haviour is incompatible with the requirements ofthe code. Tradition, social approval or ostracismand economic penalties are all effective sanctionsused to enforce moral rules and ethical codes.

Rcn PROFESSIONAL CODEI have both applause and regret for the paper fromthe Royal College of Nursing. Taken paragraph by

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paragraph, the injunction against discrimination inthe second paragraph of section II is obvious butnevertheless praiseworthy, and the encouragementfor the individual to maintain his or her ownstandards by continuing self education must be anintegral part of the development of any professional.The text of paragraph 3, section II, is broadly

aligned with the current opinion that patients shouldbe encouraged to take a greater share of the res-ponsibility for their own health. I think it is anacceptable extension of this philosophy to promotethe autonomy of a patient, as far as possible, in aperiod of illness. Curiously this view is in accordwith Illich writing in the introduction to Limits ofMedicine': 'In part at least, the health of a popula-tion depends on the way in which political actionscondition the media and create those circum-stances that favour self reliance, autonomy anddignity for all, particularly the weaker. In conse-quence, health levels will be at their optimum whenthe environment brings out autonomous personal,responsible coping ability'.Deprived of Illich's theological background the

British Medical Association was blunter in itsevidence to the Royal Commission2: 'Far moreattention should have been given to developinga sense of responsibility in the proper use of theHealth Service.... We urge appropriate healtheducation directed towards the individual's ownsense of responsibility for health.'

Paragraph 4, section II, is, I believe, well meantin intention but confusing in effect. Black and whitecases are easy to deal with; if more nurses thoughtcarefully about the actions and prescriptions ofdoctors with whom they have not worked before,there would be fewer cases of locum 'doctors'turning out not to be registered medical practitioners.Unfortunately most of real life lies within a greyarea where responsibility, individual expertise andbeliefs are combined in a complex interaction. Inthis context I agree entirely that nurses have theright and duty to express opinions about the effectprocedures may have on the patients under theircare but surely only a small minority ofnurses wouldcare to make definitive statements about whether ornot particular forms of treatment are inappropriateor whether or not a clinical experiment is unneces-sarily risky. The controlled trials that were even-tually done on streptomycin in the treatment oftuberculosis is an obvious example of balaced riskand benefit. Until the outcome of the trials wasknown even the designers of the trial procedureswith an overview of the whole were unable to makean informed judgment.The major criticism of the document must be,

however, that it is not based on present, establishednursing pattems of work. The paper appears to benot so much an attempt to set down a moral code fornurses, essentially a conservative exercise, as aradical revision of the boundaries between nursing

care and other workers' spheres of action within thehealth service. Patients also participate in the healthservice and there are sections of the document thatrelate less to the needs of patients than to those ofthe nursing profession. For example, a person whois sick tends to regress slightly in behaviouralterms, wishing to hand the responsibility for hisrestoration to good health to another person.Usually the doctor is the person who accepts theresponsibility for the patient's restoration to goodhealth, and I believe that for the benefit of thepatient it is necessary for there to be a clear role forthe doctor as the leader of a group of peopleproviding care for the patient. It is for this reasonthat I believe the multidisciplinary team approachfails when it is combined, as is now common, withdecision making by consensus.Darwin said that form must follow function and

events will show whether or not the Royal Collegeof Nursing has cast its professional code in a mouldthat the nursing profession will subsequently fit.If it has, the result will be owed partly to a lack ofable leadership by the medical profession. Ibelieve that the Royal College of Nursing hasproduced a political document, a manifesto of a sort,seeking to lead or push nurses into unrecognizedpatterns of work. This discussion document mayindicate the way to an inevitable future, but Iregret that I do not think the patients will bebetter served in that future.

References'Illich, Ivan, Limits to Medicine, Pelican, London, I977.2British Medical Association, Evidence to the Royal

Commission on the National Health Service.London, 1977.

A T Altschul Department of Nursing Studies,University of Edinburgh

On whose authority?

The value of a discussion document inevitablydepends on the authority of those who issue it, onthe composition of the group which discusses it andon the sphere of influence of those who are in aposition to disseminate their view.

This document lacks any reference to the authorityof its authors and consequently loses much of theimpact it ought to have. It is simply not goodenough to print an undated, unsigned and un-explained 'code of conduct' presumably in thebelief that the letters 'Rcn' command blindobedience.The International Council of Nurses (ICN) has

already formulated a 'code of ethics' which consistsof a mixture of a description of the role and functionof nurses and a codified pious hope. In so far as the

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prescriptive statement refers to 'moral' values, itdoes not help nurses to identify what behaviourwould meet the commands. For example, 'the nurseshould at all times maintain standards of personalconduct which reflect credit upon the profession'.What conduct would do this andwhy is it important ?This discussion document avoids the traps the

ICN has fallen into. Reading the text verticallythere are statements about the essence of nursingwith which few would quarrel: given that oneaccepts the introductory statement that nursing hasa commitment to promote optimal standards ofhealth, the list of what nurses should and should notdo follows logically. The document goes further,though, than to enunciate what nurses should do.It declares that some of the nurses' actions need tobe guided and evaluated by moral standards andthen proceeds to discuss what these moral guide-lines are. Reading the two columns horizontallyhelps the nurse to consider specific examples ofmoral issues and appropriate behaviour.

The autonomy of patients

For many nurses the section on the autonomy ofpatients will be of special concern. The documentdiscusses situations in which this may not bepossible, for example, in the case of potentiallyviolent patients or of those whose behaviour en-dangers their own safety.

I should like nurses to think deeply about thesignificance of autonomy in people's lives. Thepsychologist Erikson' may be right when he saysthat the achievement of autonomy is the properdevelopmental task of the toddler at the time whenhe gains muscular and anal control. He believes thatfailure to achieve autonomy results in the experienceof shame and doubt. Erikson does not say what.happens if later in life muscular and bowel controlis lost, but nurses can readily observe in patientswho are incontinent, who need to be assisted withevery movement of limbs, or whose movement hasto be restricted, how devastatingly they experienceshame and doubt.Of course nurses should strive to support the

autonomy of patients at all stages of illness. But,perhaps they must also learn the more difficult taskof assisting patients to accept help and controlwithout shame. Unwittingly nurses may be par-ticipants in fostering the humiliating routines ofhospitals which Goffnan 2 has so aptly identified asinstitutional life. They will have many opportunities,not only for removing constraints, but for helpingthe patient to accept these with dignity.With mentally disturbed patients increased self

respect may be a powerful factor in reducing dis-turbed and violent behaviour. Guidelines of thekind the Rcn and the Royal College of Psychiatristshave issued are needed to deal effectively withemergencies3. As soon as the emergency is over,

nurses and patients need to repair the damage whichmay have been done to the autonomy of both.

Concern of nurses with social and politicalissues

It is refreshing to read in a document of this kindthat nurses are not expected to live a life of 'angelic'purity and that they have the right to conduct theirprivate lives without undue interference, indeedthat they should be concerned with political andsocial issues whenever these are 'relevant to theprevention of disease and the delivery of healthcare'. It would seem difficult to think of any socialor political issue which. fails to quality on thosecriteria.

I welcome the explicit admission that nurses anddoctors or other coworkers may at times find them-selves on different sides of a fence and that relation-ships between nurses and members of other pro-fessions should be based upon respect for eachother's area of expertise. I subscribe wholeheartedlyto the belief that procedures should be establishedfor regular interprofessional consultation. I agreethat nurses should be concerned to establishrelationships of trust. How this is to be achieved isunfortunately not described. The main objective ofinterprofessional discussion groups must thereforebe to address themselves to the task of developingtrust and respect.

References'Erikson, E H, Childhood and Society, Harmondsworth,

Penguin, I965.2Goffman, E, Asylums, Harmondsworth, Penguin, I968.3Royal College of Nursing and National Council of

Nurses, The Care of the Violent Patient, Report ofthe Liaison Committee with the Royal College ofPsychiatrists, I972.

Chris Sampson Rcn Student Association Officer,London*

Some students' contributions

Many students thought that there should be moreemphasis placed on new social and socio-politicalconditions in our society.They considered that the poor staffing situation,

which has become a way of life in most Britishhospitals and community services, does not alwaysallow nurses sufficient time to give the full amountof attention to both the patient's physical andmental wellbeing. Pressure of work can lead to anapparent lack of sympathy.

*The views expressed are not necessarily those of theRcn Association of Nursing Students or the RoyalCollege of Nursing.

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INDUSTRIAL ACTIONOn the subject of industrial action most studentsthink that they have a duty to ensure the safety ofpatients when colleagues or other health care workerswithdraw their labour. A few thought that it mightbe necessary to withdraw their labour in extremesituations when improvements in standards of careare denied by employing authorities. This actionwould only be contemplated in extreme situationsand only in units where patients' lives would not beat risk, for example in day hospitals.

PROFESSIONAL STANDARDSThe students thought that the responsibility forprofessional standards in nursing must rest withnurses. They also considered that 'at home or inhospital', in the context of health care patterns, wasa limited view of a much wider range of nursingactivities.

RESPONSIBILITY TO COLLEAGUESAs a profession, nursing is less mature than many,and there is a great need for expansion and definitionof roles within nursing to come from within theprofession. A good team relationship is based onrespect and nursing students should be treated asteam members. Their lack of experience is notdisputed but they are in training for a professionalqualification and are not just an extra pair of hands.The statement that free discussions for establishedprocedures should be encouraged was welcomed.For too long hierarchical structures have preventeda development of the 'questioning attitude' whichis so overdue in nursing.

PROFESSIONAL RELATIONSHIPSThis section caused concern as it appears to limitthe development of discussion about the autonomousrole of nurses in certain areas of practice.

PERSONAL RESPONSIBILITYOn the subject of personal responsibility manystudents believe that so long as the nurse's ability towork effectively is not impaired her private lifeshould remain outside the purview of employersand managers.

Alexander McCall Smith Faculty of Law,University of Edinburgh

Cessation of treatment, autonomy and consent

Like others in the medical and associated professions,nurses are obliged to operate under the shadow ofthe civil and criminal law. Frequently this shadowis ill defined; the legal position may be clear onsome matters, but on others there may be some un-

certainty as to what the law is. This may be explainedin part by the absence of legislation dealing directlywith the professional responsibility of the nurse orthe doctor, but it is also a result of the curiouscircular relationship between law and medicine.The law may ultimately be called upon to definewhat is acceptable conduct on the part of theprofessions, but it tends to do so on the basis ofwhat the professions themselves suggest. The law,then, looks for guidance to professional consensus,while the professions naturally look to the law for astatement on what they can or cannot do. In thesecircumstances the promulgation of a code ofprofessional conduct is of major legal significance,in that it can be influential in the moulding of legalattitudes.From the legal point of view the fundamental

responsibility of the nurse, as stated in section IIof the Code, is unexceptionable. It might beinteresting, however, to speculate as to what subtledifferences there may be between the expression'well being and dignity of each ... person' (theterms used in the Code) and the expression 'the lifeof each patient' (not used in the Code). Here there israised a fundamental problem of legal responsibilitythat undoubtedly presents real and sometimesagonizing dilemmas for many nurses. The law doesnot allow euthanasia, nor, in the practice's moreobvious or objectionable forms, does the presentmoral consensus condone it. Yet nurses daily facethe problem of the not-to-be resuscitated patient,the deformed baby which is not given medicaltreatment it may require to stay alive, or thegeriatric patient who is not given antibiotics tocombat an infection. These instances of passiveeuthanasia can theoretically lead to both criminaland civil liability on the part of the nurse as muchas on that of the doctor. The nurse who condones orassists in the cessation of treatment (where thetreatment falls into the category of 'ordinary' asopposed to 'extraordinary' treatment') might intheory be prosecuted for culpable homicide(manslaughter in England). The practical likelihoodof such prosecution is slight, particularly in countrieswhere the decision to prosecute is reserved toofficial prosecutors, but the possibility still exists.Behind much of the reluctance to turn off therespirators in the Quinlan case in the United Stateswas concern over the possible criminal and civilliability of the medical staff involved.2The bringing of a civil action against a nurse who

fails to take all reasonable steps to ensure thecontinuation of a patient's life is similarly feasible.In both cases a nurse may attempt to shelter undera 'respondeat superior' argument and place allresponsibility with the doctor, but in theory thereis no reason why she should succeed with thisapproach.3 The specific assumption in the Codeof responsibility for the 'total effects of medicaland nursing ci-' might conceivably contribute to a

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court's unwillingness to relieve a nurse of anydegree of responsibility for her actions. Theexplanatory text refers to the duty of a nurse toquestion life-sustaining procedures which impingeupon the dignity of the dying patient. This assumesthat no adverse legal consequences will flow fromthe withdrawal of these procedures, an assumptionwhich I have suggested is currently unjustified.The question of the patient's autonomy is

directly raised in two sections of the Code, II.3,which stresses autonomy during illness, and II.4,which deals with the safety aspects of, inter alia,experimentation. Autonomy tends to be as difficulta concept in concreto as it is in abstracto. Section II.3refers to 'open and sensitive communication', butthe explanatory text declines to deal with thedifficult issue of the patient's right to know. Somecodes now stress the patient's right to informationabout his condition,4 but in the absence of suchguidance the law is far from clear. A clear expressionin the Rcn Code of the patient's right to informationand a more explicit rejection of paternalism mightinfluence the development of a firmer legal principleof the requirement of a full and informed consentto treatment.

Informed consent in the context of humanexperimentation, a hardy annual of much medico-legal debate, could well be stressed to a greaterdegree than it is in the current discussion document.The explanatory text stresses the right of the nurseto question the design of an experiment whichinvolves discomfort or risk to patients, but theimplications of the phrase 'experimentation withoutproper consent' are not expanded upon. The expresseschewal of 'legal formulae' is certainly under-standable, but in the light of the legal and ethicalconfusion surrounding this question there mighthave been more discussion of the concept of'voluntary and informed' consent. The expression'proper consent' is superficially adequate, butbehind it lies a sea of juridical problems. Shouldexperimentation ever be allowed when the subjectis institutionalized in any way? (The disclosures ofexperimentation on prisoners and residents ofhomes for old people in the United States haveraised fundamental ethical and legal problems.)Moreover, what degree of risk should the subject

be allowed voluntarily to assume ? These arequestions which, given the assumption by nurses ofresponsibility for the wefare of those they nurse,are of direct concern to any nurse involved inexperimental procedures.Apart from those circumstances in which a nurse

has a particular responsibility for the welfare ofthose in her care, she can, of course find herselffaced with the Levite/Samaritan choice in respectof members of the general public. In view of theappalling absence of 'good samaritan' legislation inEnglish-speaking countries,5 it might be argued thatthe gap should be filled wherever possible by theclear expression of a duty to render assistance tothe injured (something on which the Code issilent). In the western European legal tradition,the duty to rescue is clearly stated in the criminalcodes; in the Anglo-American legal systems no suchduty exists. In the latter systems there is thereforeno obligation to aid those in need of assistance, andin law this applies both to doctors and nurses. Aforceful rejection of this unsatisfactory principleby the professions most intimately concerned mighthelp to persuade the law to abandon its unfortunateand unconscionable stance.

References'Robertson, J A, Involuntary Euthanasia of Defective

Newborns: A Legal Analysis, Stanford Law Review,I974, 27, 213-269.

2Note, The tragic choice: termination of care for patientsin a permanent vegetative state, New York UniversityLaw Review, I976, Si, 285-3I0.

3Some Canadian decisions have stressed that providedthe nurse does as she is instructed, she will not beheld civilly liable. On this, see Bernardot, A, Laresponsibilit6 civile de l'infirmi6re, Revue de DroitUniversite de Sherbrooke, I972, 3, I-4I, at p. II.This view does not necessarily represent prevailinglegal opinion.

4American Hospital Association's Statement on aPatient's Bill of Rights, I972. See Kornprobst, L,Les droits de l'homme malade devant les nouveauxprogrammes therapeutiques. Rapport juridique,Revue des droits de l'homme, I974, 7, 528-540.

5Rudzinski, A, The duty to rescue: a comparativeanalysis in Ratcliffe, J, The Good Samaritan and theLaw, Doubleday, New York, I966.

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