An Ethical Dilemma Case Study
Instructions
Harry Nelson has end-stage cancer and has exhausted all treatment options. He is currently receiving palliative care at the home where he has raised a family. He has not as yet prepared an Advanced Care Directive. Harry’s condition deteriorates: he is increasingly breathless and is having difficulty swallowing both food and fluids. However, though very weak, Harry is alert and fully aware that his death is imminent. He has always said that he wished to die in his own home. Harry’s daughter Stacey becomes distressed and calls for an ambulance because she believes that her father could live longer if he received further treatment. She is especially worried about him choking when he drinks. A crew arrives to find considerable conflict. Despite phone calls to the palliative care team, there seems no way to resolve the conflict between Harry’s desire to stay at home and the insistence with some force by Stacey to transport her father to hospital. According to ambulance guidelines, Harry meets the criteria for medical treatment and transport. The crew transports Harry despite his objections.
From the case study above, address the following points:
- Identify at least one ethical conflict in your chosen scenario
- Propose
and discuss a legally and ethically defensible approach to addressing the
identified ethical conflict(s). In doing so, consider the conflict(s) in
relation to
- the relevant principles of health care ethics;
- the relevant professional code of ethics (if available)
- the relevant code of professional conduct
- other national and international charters; and
- one ethical theory that informs professional health care practice
Solution 1
An Ethical Dilemma Case Study
Nurses frequently face ethical dilemmas in their line of work. Sometimes, they are faced by the conflict of deciding between two right decisions, where each one poses negative legal or ethical consequences. Harry Nelson is a stage-four cancer patient who has received all relevant treatments and therefore only receives palliative care. His wish is to die at home. However, when his daughter called an ambulance, he was forcibly taken away by the paramedics. This report will highlight the ethical dilemma of the nurse in charge of the patient, the underlying principles that could apply to the situation, the ethical theory that could help formulate a solution, the applicable frameworks of justice, and the solution to the dilemma. Since the process of finding a solution will give rise to conflicting principles, the possible answer to the solution is embracing the deontological theory.
The Arising Ethical Dilemma
The existing ethical conflict entails choosing between the patient’s right to refuse care and the professional duty of care (Davis et al., 2010). Harry’s decision is to stay in the house where he raised his children and spent most of his time with his family. He does not consent to living in the hospital, where he would receive advanced palliative care. The medical practitioners could therefore respect the patient’s right to refuse treatment. However, the decision brings to question whether the nursing professional’s work entails reducing the suffering of patients or negligence (Horton et al., 2007; Tarlier, 2004). Admitting the patient to the hospital according to the daughter’s wishes would help fulfill the purpose of medical specialty. There would be the elimination of negligence in nursing duties. However, this choice could result in the question of whether people can receive treatment by force, thus overlooking one’s wishes (Shahriari et al., 2013). Evidently, the nurse in charge of the patient is caught between making two morally right decisions, depending on the principles and the ethical theories one embraces.
The Principles that Apply to the Case
One of the principles that are applicable to the case is beneficence. The ethical standard entails that nurses embrace actions that promote what is best for the patient. Working under this principle, the nurse has to look out for the well-being and interests of the client (Pojman, 2010). Evidently, the concept of what is good is imperative since the principle does not give a definite definition of what is good. In this case scenario, the nurse may opt to adhere to the wishes of the patient and set him home. This is because he would receive love from family members. Moreover, the patient is aware that he only has a few days left and it is right to act according to the wishes of a dying man (Thompson, 2006). If the nurse were holding a different moral perspective, she would prefer to offer the required medical services (Kinsinger, 2010). Thus, the client would stay in the hospital to receive the best care. Evidently, the principle of beneficence gives rise to conflicting options on what is morally appropriate.
Another principle that a nurse can apply to the case of Harry is non-maleficence. The concept entails the protection of the patient from any harm. The medical professional should refrain from acts that violate the welfare interests of the client (Beauchamp & Childress, 2009). When applying this principle, the nurse may perceive the administration of palliative as essential in reducing the suffering of the patient. The act would therefore refrain from harming the client physically. On the other hand, a nurse could opt to act according to the client’s desire of staying at home (Davidhizar, 2005). Although Harry would not be receiving proper care, he would have emotional comfort in spending his time with his family. Thus, there would be limited harm caused to the emotional welfare of the patient (King & Broom, 2002). Clearly, there is an underlying conflict on whether to take care of the emotional or physical well-being of the patient.
The third principle in play is autonomy, which asserts that one has the right to make decisions concerning their lives independently (Sneddon, 2013). In this case, there is a violation of this right due to the interference of the daughter of the patient. Another evidence of obstruction of self-determination is the paramedics who brought the patient to the hospital amidst his objections. The nurse could honor his decision by releasing him from the hospital. However, this may give rise to the specialist feeling that her autonomy is ethically violated (Shih et al., 2009). There would therefore be a developed reluctance to obey the patient’s will in case the patient may make decisions that are against the nursing practices. For example, nurses are required to reduce the suffering of dying patients. This expectation grants nurses their own autonomy when they decide to offer treatment (Chitty & Beth, 2007). On the other hand, Harry has the right to refuse care. Plainly, there is a conflict on granting Harry the right to refuse care versus the autonomous authority of the nurse.
Lastly, human dignity is a key principle that influences the perception of the case. Nurses respect the dignity of their patients by understanding them and working towards the fulfillment of their needs, preservation of the sense of the meaning of life, and adhering to the set human rights (Lachman, 2006). The principle gives rise to two possible conflicting decisions. One of them is through understanding the needs of the client by granting him his right to refuse care from the specialists. This decision could preserve self-worth since Harry could feel that he is in a position of making decisions concerning his life (Sharp, 2009; Naden & Eriksson, 2004). Moreover, he could have a sense of the meaning of life because of spending time with his family. On the other hand, dignity entails valuing human life. This is evidenced by reducing the level of suffering through giving the appropriate care. This asserts the need for the patient to have hospital care.
Deontological Approach
Evidently, the four principles do not give a definite way of solving the conflict but only highlight the pros and cons of the patient’s right to refuse care and the professional duty of care. The nurse could focus on solving the case by embracing the deontological theory of ethics (Niebroj, 2008). The approach requires that the nurses embrace the set rules that define one’s duty (Butts & Rich, 2008). In this case, the nurse in charge should act according to the nurses’ code of ethics, the code of professional conduct of nurses in Australia, and the Australian Charter of Healthcare Rights.
The Code of Ethics for Nurses includes two of the discussed principles, which are respect for human dignity and autonomy. The second provision holds that the nurse should engage the patient in the process of planning for care. (Enright, 2001) The interests of the patients should be reflected since they reflect the uniqueness of the client. Conflicts of interest may arise and so the nurse has the responsibility of solving the conflict. Nonetheless, she should remain committed to the patient. The commitment ought to reflect the patient’s best interests, patient safety, and the integrity of the profession (NMBA, 2008). Application of this provision indicates that the nurse should try to settle the conflict between the daughter and father concerning his health. Nonetheless, the nurse should uphold the objectives of the profession, which are giving the best care to the patient (Rancich et al., 2005). However, there exists a conflict in protecting the integrity of the profession. One could adhere to the interests of the patient or force treatment thus denying the right to refuse treatment.
The Code of Professional Conduct for Nurses in Australia acts as a guide for selecting the best-fit decision in case of an ethical dilemma. The first statement indicates that medical experts should provide safe and competent care to patients. Harry’s case requires that the nurse provide care that reduces suffering and prolongs his life. In case there is a violation of this standard, the nurse is expected to report to the appropriate people in the health facility. However, the fourth statement of the code provides that the nurses respect the values and beliefs of the patients (NMBA, 2008). The nurses should uphold these values during the planning and provision of care. However, they can facilitate the making of sound and informed decisions by addressing the patient. Thus, Harry’s nurse has to respect his wishes but could inform him of the necessity of receiving care at the hospital.
The Australian Charter of Healthcare Rights provides that everyone has a right to access healthcare. All patients can access the best standards of physical healthcare (Victoria State Government, 2017). Consideration of this principle indicates that Harry should consult healthcare specialists instead of staying at home where he does not receive proper treatment. However, this decision is dependent on Harry. The charter provides that patients should participate in making decisions concerning the care they receive. In case a patient who is an adult and of a sound mind refuses treatment, the nurses should comply (Rassin, 2009). In this case, the nurse in charge is required by the charter to take into consideration the wishes of the patient. She should not force him to receive care. The only way she could therefore help is issuing information that could help influence the decision of the patient (Jormsri et al., 2005).
Recommended Action
The discussed codes do not issue a precise decision for Harry’s ethical dilemma. They conflict on the right cause of action. The code for nurses, for example, indicates that the medical specialists should solve conflict and act according to the best interests of the patients. The meaning of the term ‘best interest’ varies from one person to another (Jhonstone, 2004; Verpeet et al., 2005). While one specialist may understand best interest as spending the last days with family, another may comprehend it as receiving the best care to prolong life and reduce suffering. Thus, a nurse’s intervention in conflicts increases biased decisions that tend to embrace the moral theories one embraces. The code of professional conduct and the Australian Charter of Health Care Rights, on the other hand, entails inclusion of the patient in the planning of the care he receives. The decision could incline to the biasness of the patient’s interests without considering the option for giving the ‘best medical care’ (Baumrucker et al., 2008).
It is therefore important to consider relevant case laws that entail choosing between patient’s refusal of treatment and fulfillment of professional duty of care. In the Hunter & New England Area Health Service v. A [2009] NSW SC 761 case, Mr. A had signed a directive indicating his withdrawal from treatment. He had authorized Mr. T to act his guardian, who would refuse the administration of the treatment. In court, the Judge indicated that preservation of life is taken into account with the attributes of life. Thus, one cannot overrule the concepts of autonomy. This is only applicable when someone makes the decision voluntarily and with a sound mind. Applying the verdict on Harry’s case, Harry made the decision of staying with his family during his last days. His right to refuse treatment preside the nurse’s professional duty. However, before making this decision, there is a need to seek the help of senior professionals, in accordance to the seventh provision of the Code of Professional Conduct for Nurses in Australia, which indicates that the nurses report such cases to people in authority.
Conclusion
Harry
Nelson’s medical case presents a dilemma of choosing between professional duty
of care and the patient’s right to refuse healthcare. Although the principles
of beneficence, non-maleficence, human dignity, and autonomy can be applied to
the case, they do not give a definite approach to the problem since they reflect
the possible arising moral conflicts. The outlined codes and international
tribunals that govern nurses in their work also do not give a definite answer
to the issue. There is therefore a need to consider similar case laws that
could help identify the best approach to the problem. The code of nurses
indicates working for the ‘best interest’ and involving the patient in the
decision making. The Australian Charter for Health Care Rights and the code of
nurses for professional conduct also support the inclusion of patients in the
planning for care. Nonetheless, the assistance from a senior professional could
help develop the most feasible decision.
References
Baumrucker S., Sheldon J., Stolick M., & VandeKieft G. (2008). The ethical concept of “best interest” Am J Hosp Palliat Care, 25, 56–62. (6.31-6.32): DOI:10.1177/1049909107313130
Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics. New York, NY: Oxford University Press
Butts, J. B., & Rich, K. L. (2008). Nursing ethics across the curriculum and into practice. Sunbury, MA: Jones and Bartlett
Chitty K., & Beth B. (2007). Professional nursing concepts and challenge 5th ed. St Louis: Saunders Elsevier.
Davidhizar R. (2005). Benevolent power. J Pract Nurs, 4, 5–9. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/16512263
Davis, A. J., Fowler, M. D. M., & Aroskar, M. A. (2010). Ethical dilemmas & nursing practice. Boston: Pearson.
Enright W.G. (2001). Building a cathedral for your soul: generosity as a virtue and a practice. Otolaryngol Head Neck Surg, 138, 552–556. 6.31-6.32): doi: 10.1016/j.otohns.2008.02.013
Horton K., Tschudin V., & Forget A. (2007). The value of nursing: A literature review. Nurs Ethics, 14, 716–40. 6.31-6.32): DOI: 10.1177/0969733007082112
Hunter & New England Area Health Service v. A [2009] NSW SC 761 retrieved from http://www.austlii.edu.au/au/cases/nsw/NSWSC/2009/761.html
Solution 2
There is an ethical conflict present in the scenario described above in that Harry’s wishes to remain at home and receive palliative care are in conflict with his daughter Stacey’s desire for him to receive further treatment at a hospital. This conflict arises due to a difference in values and priorities, with Harry valuing the autonomy and comfort of remaining at home while Stacey is concerned with prolonging his life for as long as possible.
One legally and ethically defensible approach to addressing this ethical conflict would be to prioritize Harry’s autonomy and decision-making capacity. According to the principle of respect for autonomy, which is a fundamental principle of health care ethics, individuals have the right to make decisions about their own healthcare and should be respected in their choices (Beauchamp & Childress, 2009). This means that Harry has the right to choose to receive palliative care at home rather than being transported to a hospital against his wishes.
This approach is supported by the relevant professional code of ethics for healthcare professionals, such as the Code of Ethics for Nurses (International Council of Nurses, 2020), which states that nurses should respect the autonomy of individuals and support their right to make decisions about their own healthcare. It is also supported by the relevant code of professional conduct, such as the Code of Conduct for Health Care Workers (World Health Organization, 2018), which emphasizes the importance of respecting the dignity, autonomy, and rights of individuals.
In addition, this approach is consistent with international charters such as the Universal Declaration of Human Rights (United Nations, 1948), which guarantees the right to self-determination and the freedom to make decisions about one’s own healthcare. It is also informed by ethical theories such as principle-based ethics, which holds that ethical actions should be guided by moral principles such as respect for autonomy (Beauchamp & Childress, 2009).
However, it is important to note that while respecting Harry’s autonomy is a crucial ethical consideration, it is not the only one. The principle of beneficence, which requires healthcare professionals to do good and promote the well-being of their patients, also comes into play in this scenario (Beauchamp & Childress, 2009). Stacey’s concern that Harry may choke on fluids is a legitimate one, and it is important to consider the potential risks and benefits of various courses of action.
One potential way to address this ethical conflict while still respecting Harry’s autonomy would be to involve him in the decision-making process and have an open and honest conversation about his wishes and concerns. This could involve discussing the potential risks and benefits of receiving further treatment at a hospital or remaining at home, as well as exploring potential alternatives such as adjusting his care plan or using assistive devices to help him swallow. Involving Harry in the decision-making process can help to ensure that his autonomy is respected while also considering his overall well-being and the concerns of his family.
It may also be helpful to involve a healthcare professional with expertise in palliative care, such as a hospice nurse or palliative care physician, to provide additional guidance and support in decision-making. These professionals can help to ensure that Harry’s physical and emotional needs are being met and that his care plan is aligned with his goals and values.
In conclusion, a legally and ethically defensible approach to addressing the ethical conflict in this scenario would be to prioritize Harry’s autonomy while also considering his overall well-being and the concerns of his family. This could involve involving Harry in the decision-making process and exploring potential alternatives, as well as seeking guidance and support from a healthcare professional with expertise in palliative care. This approach is supported by ethical principles, professional codes of ethics and conduct, and international charters
References
International Council of Nurses. (2020). Code of Ethics for Nurses. Retrieved from https://www.icn.ch/sites/default/files/inline-files/ICN%20Code%20of%20Ethics%20for%20Nurses%20revised%202020.pdf
United Nations. (1948). Universal Declaration of Human Rights. Retrieved from https://www.un.org/en/universal-declaration-human-rights/
World Health Organization. (2018). Code of Conduct for Health Care Workers. Retrieved from https://www.who.int/publications/i/item/9789241514594