Introduction to Fidelity

The principle of Fidelity is a fundamental aspect of the “super-principle” of Respect for Persons. It concerns the moral obligation to remain faithful to commitments and to keep promises made to others.

Key Terms

  • Fidelity: The ethical principle of keeping promises and commitments.
  • Confidentiality: The obligation to keep a patient’s personal and private information secret.
  • Privacy: The right of a person to be free from unwanted intrusion or disclosure of personal information.
  • Explicit Promise: A direct, verbal, or written commitment.
  • Implicit Promise: A commitment assumed to exist based on the nature of a relationship (e.g., the nurse-patient relationship).

Learning Objectives

By the end of this session, students should be able to: 1. Define the principle of fidelity and its relation to respect for persons. 2. Describe the types of commitments typically made by nurses in patient care. 3. Analyze situations where breaking a promise may be morally permissible. 4. Identify the limits of confidentiality in nursing practice.

1. Philosophical Foundations of Fidelity

The duty to keep promises is viewed differently depending on the ethical framework applied:

A. Consequentialist (Utilitarian) View

  • Logic: Promises should be kept because the act of promising would become useless if they were routinely broken. Breaking promises generally leads to bad outcomes (loss of trust).
  • Application: A promise might be broken if doing so produces a significantly better “net good” for the patient or society.

B. Nonconsequentialist (Formalist/Deontological) View

  • Logic: Keeping promises is an inherent “right-making” characteristic of an action, independent of the consequences.
  • Application: Breaking a promise is prima facie wrong. It requires an overwhelming counter-obligation (like saving a life) to justify the breach.

2. Promise Keeping in Nursing

Nurses make both explicit and implicit promises daily. The nurse-patient relationship is often described as a covenant or contract.

Case 9-1: Breaking a Promise to Do Good

  • Scenario: A nurse promises an elderly, confused patient she won’t “let them do” Electroconvulsive Therapy (ECT). However, the nurse believes ECT is in the patient’s best interest.
  • The Dilemma: Does the nurse’s duty of beneficence (doing good) override her duty of fidelity (the explicit promise)?
  • Key Question: Is it deceptive to rationalize that “I didn’t let them ‘harm’ you” if the patient perceives the treatment as harm?

Implicit Promises and Law

  • Case 9-2: Examines the conflict between the implicit promise to provide care/not abandon a patient and the legal requirement to report/deny care to illegal immigrants.
  • The Dilemma: Conflict between the promise to obey the law and the professional promise to serve the patient.

3. Confidentiality

Confidentiality is a specific application of fidelity. It is the commitment not to disclose information learned during the clinical relationship.

Theoretical Bases for Confidentiality

  1. Beneficence: Keeping secrets encourages patients to be honest, leading to better care.
  2. Privacy: Grounded in the right of people to control their own information.
  3. Fidelity: Grounded in the explicit or implicit promise made at the start of the relationship.

Professional Codes (Table 9-1)

  • Nightingale Pledge: “Hold in confidence all personal matters.” (Absolute)
  • ANA Code: “Duty to maintain confidentiality… not absolute and may need to be modified to protect the patient [or] other innocent parties.”
  • ICN Code: “The nurse holds in confidence personal information and uses judgment in sharing.”

4. When Is It Permissible to Break Confidence?

The text explores three primary scenarios where confidentiality may be challenged:

A. When the Patient May Be Harmed

  • Case 9-3 & 9-4: A pregnant teenager wanting an abortion without her mother knowing; a mother wanting to bond with a child she plans to give up for adoption.
  • Paternalism: Breaking confidence for the “good” of the patient is highly controversial and often violates autonomy.

B. When Others May Be Harmed (Duty to Warn)

  • Case 9-7 (The Nurse Addict): A nurse discovers a colleague is using cocaine. Fidelity to a friend/colleague vs. duty to protect future patients from an incapacitated caregiver.
  • Case 9-8 (Sexual Assault): A patient claims assault but begs the nurse not to tell the police. Does the nurse have a responsibility to warn society/police about a dangerous assailant?

C. When Required by Law

  • Case 9-10: Mandatory reporting of suspected child abuse or neglect.
  • Rule: Patients generally have no right to expect confidentiality when a public law requires disclosure (e.g., gunshot wounds, infectious diseases, child abuse).

Critical Thinking Questions for Discussion

  1. What explicit and implicit promises do you make to patients simply by appearing in uniform?
  2. Reflect on common “minor” promises (e.g., “I’ll be right back”). What are the consequences of failing to fulfill these?
  3. If you were the nurse in Case 9-5 (colleague’s medication error), would the lack of “residual harm” to the patient justify keeping the secret, or does the duty to the profession override the duty to the colleague?
  4. How do you balance the “Duty to Warn” a spouse about HIV status (Case 14-4) against the risk of domestic violence toward the patient?

Notes adapted from: Fry, S. T., Veatch, R. M., & Taylor, C. (2011). Case Studies in Nursing Ethics (4th ed.). ```