Ethical Dilemmas in Nursing

In order to provide professional competence, nurses must be familiar with ethical theories. Ethics are often central to nursing because a nurse’s daily obligations will frequently consist of considering ethical conundrums and issues. While nurses are responsible for their own participation and actions, they are equally obligated to support patients who need to make their own ethical decisions. Considering moral behaviors and ethics allows nurses to analyze moral problems from a variety of perspectives. Because problems often have more than one solution, recognizing four ethical principles such as respect for patient autonomy, nonmaleficence, beneficence, and justice and implementing them with theories such as Utilitarianism and Deontology allow nurses to provide their patients with high quality ethical care.  

Medical and healthcare teams rely on ethical theories to govern their behavior whilst in the work setting. Noureddine (2001) revealed that “The ethical agents are the client and the nurse [and] The nurses responsibility is to combine scientific knowledge, concern for humanity and self-engagement in his/her caring” (p. 6). Specifically, Noureddine (2001) has noted that Utilitarianism focuses on the greater good for society as a whole. Williams (2009) agrees that “Utilitarians look at outcomes, not intentions” (pg. 50). On the other hand, Deontology relies on our moral values to reveal the right or wrong course of action and “place a high value on duty or obligation” (Noureddine, 2001, p.3). Like the principle of autonomy, deontological theory focuses on individual welfare (Noureddine, 2001).

Autonomy, nonmaleficence, beneficence, and justice are the major principles in deontology (Noureddine, 2001, p.3). We often consider Deontology and Utilitarianism as opposites because one depends on action while the other considers the outcome. McNaughton and Rawling (1998) suggest Deontology is a preferable theory because it recognizes the value of “inviolability” (pg. 50). In other words, if we live our lives by our moral values, we are incapable of making decisions that would harm others. 

However, in the case of confidentiality, one would consider Utilitarianism as the preferable theory. For example, Latour and Albarran, (2012) explain that medical units’ environments change quickly and steadily, so they are prime locations in which confidentiality is at risk. Nevertheless, there are circumstances in which nurses or doctors are justified in breaking confidentiality. As an illustration, suppose one encounters a patient who reveals a deadly secret. The patient confides that he will kill his wife as soon as the hospital discharges him, but implores for discretion. In spite of patient confidentiality, the nurse must break it in order to protect the well-being of a third party. In this scenario, Utilitarianism suggests that the outcome of the patient’s actions will result in possibly more than one lost live, so it is the outcome of the action that is problematic. If the patient decided to dispose of his wife by planting a bomb in her office building, the outcome of his action would harm a greater portion. 

A central ethical issue involves the principle of confidentiality. The American Nurses Association (ANA) Code of Ethics for Nurses states that “only information pertinent to a patient’s treatment and welfare is disclosed, and only to those directly involved with the patient’s care” (Provision 3, 2010).  In other words, it is standard and necessary that nurses share relevant information with patients’ doctors, who in turn uses this data in regards to patients’ care. However, nurses may not share a patient’s information to his or her family without the patient’s consent. Reasonable limits would include suspected abuse or possible third party harm. For example, a nurse would have the right to break patient confidentiality clause if he or she finds that the injuries reveal that the patient was injured while participating in a murder. Thus, the nurse is obligated to report this information to law enforcement. 

On the other hand, if a nurse cares for a patient who has received a troubling diagnosis, but does not want to share it with his or her family, the nurse is unable to break confidentiality because he or she must respect the patient’s autonomy. As an illustration, the case presentation demonstrates the liability of confidentiality. Upon Mrs. Z’s diagnosis of cancer, Mrs. Z tells the nurse and physician in attendance that she does not want to reveal her medical condition to her family and she refuses to undergo treatment. Subsequently, her husband Mr. Z asks his university colleague Dr. J to gain his wife’s records. Dr. F’s nurse does not respond to Dr. J’s request until she consults with Dr. F. Dr. F and the nurse are authorized to release Mrs. Z’s medical records as long as she gives them her consent to do so. Because her cancer diagnosis does not pose a serious threat to a third party, Dr. F would not be obligated by law to share her information. Principally, the medical concern includes Mrs. Z’s refusal to undergo, or talk of, treatment with her healthcare providers or her family. In the case of Mrs. Z, Dr. F and the nurse must resolve the ethical conflict to ascertain Mrs. Z’s reasons for not seeking treatment and not sharing her health information with her family.

Alongside ethical theories, Dr. F and the nurse would consider moral principles to aid in their decisions. Essentially, if two people cannot agree on a certain course of action, they will identify which moral principles are likely to apply. Noureddine (2001) suggests we consider criteria such as acknowledgement of personal rights, consent, and justice and integrity. Likewise, Beauchamp and Childress consider four basic ethical principles: respect for autonomy, nonmaleficence, beneficence, and justice (Pace, ed., 2010). When nurses hold respect for autonomy, nurses engage in “respectful treatment in disclosing information and actions that foster autonomous decision making” (Pace, ed., 2010, pg. 97). In addition, nurses must respect a person’s right to choose and his or her ability to act on his or her choice. Nonmaleficence is twofold: we cannot produce harm and we must take means to prevent harm. When we practice beneficence, we believe it is our duty to promote and practice behavior that is for good. Lastly, when we aim to practice justice, we promise to provide equal treatment and to essentially be fair. 

Because Mrs. Z’s cancer diagnosis does not pose a serious threat to a third party, Dr. F would not be obligated by law to share her information. In addition, Dr. F and his nurse must respect Mrs. Z’s privacy because releasing her information to her husband would disrespect her autonomy. Incidentally, Wheat (2009) suggests it is “upon the utilitarian principle that people are more likely to seek medical advice if they know that the information will remain confidential” (pg. 1063). Subsequently, Mrs. Z’s autonomy involves her right to choose and her right to act on her choice. In this case, she chooses to keep her diagnosis to herself. 

However, it is possible that cultural values have influenced Mrs. Z’s actions. Saha, Beach, and Cooper (2008) reveal “healthcare leaders and educators have recognized that cultural and linguistic barriers between healthcare providers and patients might interfere with the effective delivery of health services” (pg. 4). In this case, perhaps Mrs. Z does not understand the severity of her diagnosis due to a language barrier. Therefore, she may not understand what confidentiality entails. Also, Mrs. Z’s culture only allows female doctors to examine her. Mrs. Z told her mother-in-law about the lump, but she did not tell her husband, so conceivably her cultural values have left her to believe that males should not know a female’s health problems. Perhaps with time, she may confide in her mother-in-law.  

On the other hand, while Dr. F and the nurse respect patient autonomy, their initial concern is Mrs. Z’s health. In this way, their values reflect Western civilizations norms of access to health care and treatment to preserve life. Saha et al. (2008) reveals “both patients and providers [bring] cultural perspectives to the encounter,” but providers should specifically reflect “the privilege and power associated with their status as professionals” (page 5). For example, Jonsen et al. (2008) suggest that medical teams tend to use technical language, so patients are unable to understand. Nevertheless, Jonsen et al. (2008) maintain that doctors and nurses should not override their patient’s preferences with probabilistic futility. As an intervention, the nurse could have a frank discussion with Mrs. Z that describes the illness’s consequences. In addition, the nurse can offer Mrs. Z descriptions of what the treatments will entail. This way, the nurse provides Mrs. Z with information to help her understand her choice. 

Because medical teams will often run into ethical issues while practicing, they rely on ethical models to examine possible solutions. Jonsen et al. (2008) recommends medical teams use a four-factor paradigm to decide what ethical course they should take when faced with an ethical dilemma. Specifically, Dr. F and the nurse can discuss the medical indications, patient preferences, quality of life, and contextual features (Jonsen et al., 2008). In box one, the medical indications entail that the team review Mrs. Z’s diagnosis and options for treatment. In regards to patient preferences, the medical team must consider Mrs. Z’s preference for confidentiality. Thirdly, Dr. F and the nurse should consider Mrs. Z’s quality of life because they wish to address and improve her health. Lastly, when considering box four contextual features, the medical team deliberates the contexts of health insurance, the law, and hospital policy as well as the patient and family. 

Jonsen et al. (2008) explain that the four-box paradigm allows medical teams to methodically weight their choices. Box one reveals that she has been diagnosed; however, according to box two, Mrs. Z has declined treatment and requested her family not know. At the same time, according to box three, it is not presumable that her quality of life will be affected whether or not she is in treatment because of cancer’s natural course. In this case, Mrs. Z has exercised her preference, so the medical team can only intervene if it will benefit her quality of life. The contextual features would include Mrs. Z’s husband and mother-in-law as outside influences for her decision. While Mr. Z has a moral right to know Mrs. Z’s condition, it is actually Mrs. Z’s responsibility to tell him. Essentially, Dr. F and the nurse are unable to justify disclosure because their priority is to respect Mrs. Z’s preferences (Jonsen et al., 2006). In addition, Dr. F and the nurse are unable to override her decision because there is no indication that her family would be physically harmed due to her decision. Likewise, based on box four contextual features, Mr. Z and Dr. J are unable to offer any justification for Dr. F and the nurse to breach Mrs. Z’s confidentiality. Essentially, while Mr. Z was curious about the medical bill, it does not relieve Dr. F and the nurse to disclose her information. Overall, the medical team’s best practice would be to respect Mrs. Z’s patient autonomy; however, they can encourage Mrs. Z to talk with them about her decisions. In addition, when one considers the four most common ethical principles, Dr. F and the nurse may reflect upon autonomy and justice, so once they are able to establish there will not be any others in physical danger, they are not justified in disclosing Mrs. Z’s diagnosis. 

The nurse and patient relationship is complex and multidimensional. It is highly probable that all nurses will encounter difficult ethical decisions. Because emotions tend to run high, familiarity with applying ethical models to distressing problems will allow nurses to use empirical evidence as a factor in his or her decisions. Medical teams vary in their moral behaviors and beliefs as do their patients. Nevertheless, commitment to patient autonomy fosters meaningful relationships between health providers and patients. While we cannot always expect to develop welfare for the common good, we can be mentally responsible for our own actions.

References

American Nurses Association. (n.d.). Code of ethics with interpretative statements [PDF]. NursingWorld.org.

Ebbesen, M. (2010). Two different approaches to principles of biomedical ethics: A philosophical analysis and discussion of the theories of the American ethicists Tom L. Beauchamp and James F. Childress and the Danish philosophers Jakob Rendtorff and Peter Kemp. In T. N. Pace (Ed.), Bioethics: Issues and dilemmas. Hauppauge, NY: Nova Science.

Jonsen, A. R., Siegler, M., & Winslade, W. J. (2006). Clinical ethics: A practical approach to ethical decisions in clinical medicine. New York: McGraw-Hill, Health Professions Division.

Latour, J., & Albarran, J. (2012). Privacy, dignity and confidentiality: A time to reflect on practice. Nursing in Critical Care, 13(3), 109-111. Retrieved from http://www.ebscohost.com/

McNaughton, D., & Rawling, P. (1998). On Defending Deontology. Ratio, 11(1), 37-54. doi: 10.1111/1467-9329.00050

Moskop, J. C., Marco, C. A., Larkin, G. L., Geiderman, J. M., & Derse, A. R. (2005). From Hippocrates to HIPAA: Privacy and confidentiality in Emergency Medicine—Part I: Conceptual, moral, and legal foundations. Annals of Emergency Medicine, 45(1), 53-59. doi: 10.1016/j.annemergmed.2004.08.008

Noureddine, S. (2001). Development of the ethical dimension in nursing theory. International Journal of Nursing Practice, 7, 2-7.

Saha, S., Beach, M., & Cooper, L. A. (2008). Patient Centeredness, Cultural Competence and Healthcare Quality. J Natl Med Assoc, 100(11), 1275-1285. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2824588/

Wheat, K. (2009). Applying ethical principles in healthcare practice. British Journal of Nursing No, 18(17), 1062-1063.

Williams, D. (2009). Forensic nursing and utilitarianism: The quest for being right. Journal of Forensic Nursing, 5(1), 49-50. doi: 10.1111/j.1939-3938.2009.01031.x