The Ethics for Nursing in the Ethical Conflict Between Patient Autonomy vs. Patient Advocacy

In their clinical duties, nurses will encounter ethical dilemmas that are often troublesome according to their values, but they must remain objective. In addition, there are instances in which a nurse may feel obligated to step in and offer care to certain people that he or she believes would make a different choice had they been able to. Dana Lawrence DC MMedEd reveals that the “four principles that comprise the general working foundation for modern American bioethics [are] beneficence, nonmaleficence, justice and autonomy” (34). However, there are times that the principles may conflict. If a parent makes a decision to refuse treatment or a lifesaving procedure for his or her child, nurses may experience an overwhelming sense of helplessness because if they are unable to provide the necessary treatment, they go against the principle of beneficence in order to respect patient autonomy. 

The principle of autonomy has negative and positive obligations. Essentially, a nurse is obligated to respect his or her patient’s decisions, acquire consent for treatment, and provide patients with truthful information. In Principles of Biomedical Ethics, Tom Beauchamp and James Childress explain “in order to be an autonomous choice, a patient’s choice must be voluntary and informed” (46). Therefore, a nurse has the positive obligation of providing care and information to patients; however, the principle of autonomy may involve negative obligations because at times, nurses may feel that their patients refuse essential treatment, yet they must respect their wishes. In the case that a patient is considered incompetent, his or her family may consent to the care. Nevertheless, the medical community often wonders what to do in the case of a child. In some cases, parents may refuse to offer consent because of religious, cultural, or other factors, and the clinical team must respect their wishes. 

Consequently, if the medical team is unable to provide a child with life-saving treatment, they often feel as though they are ignoring the principle of beneficence. Beneficence suggests that nurses are obligated to provide their patients with the best care, so they are ultimately protecting their patients from harm by offering them medical treatments. Also known as patient advocacy, this principle also has negative and positive obligations. In Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, Albert Jonsen, Mark Siegler, and William Winslade emphasize that this particular principle demands that the medical team “evaluate the potential benefits of any proposed intervention in relation to the risks, to make a recommendation to the patient, and to solicit the patient’s preference about whether to undergo the treatment” (18). In other words, the medical team cannot ask the child or inform the child directly of the treatment or the consequences of not receiving treatment. Instead, they have to consult with their parents. 

When caring for patients, a multilevel disciplinary team often works together to establish the appropriate care for individuals in ethical dilemmas. However, Margaret Mahlin, author of “Individual Patient Advocacy, Collective Responsibility, and Activism within Professional Nursing Associations,” reasons “Nurses often navigate family relationships simply because they are most likely to meet patients’ families during the course of their work” (249). As patient advocates, a nurse’s first priority is patient care quality rather than hospital needs. Thus, developing a professional, yet thoughtful, relationship with parents may encourage trust. On the other hand, parents may mistake this relationship as an indication that nurses are on ‘their side’ regardless of their decisions.  

As a result, promoting patient advocacy and respecting patient autonomy is often a source of conflict.  Bernadette Gersni RN reveals in a personal interview that “Being a patient advocate is one of the most important roles we play as caregivers.” In other words, as caregivers, nurses dedicate themselves for the betterment of their patients. In the clinical environment, it is a common experience to want to protect patients; however, Gersni clarifies patients “should have autonomy in making decisions.” In his essay "Attachment, Autonomy, and Emotional Reliance: A Multilevel Model," Martin Lynch agrees that autonomy is a fundamental right. Lynch asserts “Autonomy is about the experience of choice, endorsing one’s actions at a deep level of reflection, and congruence between one’s actions and one’s personal values and beliefs” (310). Principally, autonomy allows a patient to make his or her own choices because it is his or her natural right. However, while most clinicians would agree that autonomy is a valuable principle, it often becomes muddled when it concerns a child. 

For example, Gersni recalls one experience in which her patient’s parents refused medical intervention: I had a child that was desating to 80 and parents didn’t want me to give o2 at all, saying "No, once you start giving o2 she's going to be dependent on it we already researched it" The child was bagged for 5 min but still remained 80%... [and her] parents said she will come up…[but]she stayed like that for 30 min and I felt totally useless. It was in the chart to give o2 if sats go below 92%. I explained to the parents the possible detrimental effects this was having on the child but they still refused. . . .

I asked them to get me the research they read about…and I called the ordering physician ... [and] the charge nurse involved. I felt that it was the best I could do while respecting the parents’ decision but also trying to advocate for [her] treatment (that was also an order) with getting the doctor there right away to explain. I would also not be advocating if I did not follow the orders. 

Gersni’s response was that of a patient advocate. However, in spite of the medical chart, Gersni realized that the parents were the consenting party. In this case, she understood that she had to put aside her principles for beneficence in order to respect patient autonomy. Kay Wheat explains in the article "Applying Ethical Principles in Healthcare Practice” that “Totally autonomous decision-making might at best be aspirational (it can be difficult to provide sufficient resources to facilitate fully informed decisions) but stressing its importance is key” (1063). Essentially, the need to provide care does not always correlate with the consenting party’s interests. Because Gersni asked for the parents’ research, she demonstrated that she attempted to understand why the parents did not want her to give o2. In addition, she used teamwork in order to provide the parents with further information.  

Because each individual has a differing perspective, nurses often find that they are ethical mediators. Samar Noureddine, the author of the "Development of the Ethical Dimension in Nursing Theory, explains “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” (6). On the other hand, moral reasons for acting may also depend on the “agent-relative figure…such [as] relationships…of parent to child… [and] in each case the agent’s reason for acting [is it is] her obligation to act” (McNaughton and Rawling 39). Ultimately, the goal seems to be that awareness of the illness and the appropriate interventions will allow parents to make decisions that would ultimately benefit their child. 

Specifically, the majority of parents want the best for their child, and their child often trusts them to make difficult decisions. In his article “What Limits, If Any, Should Be Placed on a Parent’s Right to Consent And/or Refuse to Consent to Medical Treatment for Their Child?” Giles Birchley argues “if best interests are to include all important viewpoints we must consider how to give voice to those of the child” (282). In other words, parents often provide their child’s voice. Because parents have the responsibility to raise their child, they may not understand the right of patient autonomy. On the other hand, they may be familiar with the concept of beneficence. Birchley proposes that “Self-determination theory holds that people prefer to turn to partners who provide support for their basic psychological needs, particularly the need for autonomy” (301). Therefore, because the child understands that he or she is under a parent’s care, and he or she trusts the parent, clinicians may have to consider that in some cases, parents do know what is best. Therein lays the struggle. 

As ethical agents, the nurse and parental relationship are multifaceted, and nurses will likely encounter difficult ethical decisions frequently. Nurses and parents will vary in their moral behaviors and beliefs, but the most important issue is that of providing care to a child in need. Thus, an understanding of patient autonomy extends to the parents because it is more than likely that they believe they are making the correct decisions for their child’s welfare. While parents and nurses may not always agree, essentially both are working towards what they feel is best. 

Works Cited

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. New York, NY [u.a.: Oxford Univ., 2009. 

Birchley, Giles. "What Limits, If Any, Should Be Placed on a Parent’s Right to Consent And/or Refuse to Consent to Medical Treatment for Their Child?" Nursing Philosophy, vol. 11, 2010, pp. 280-85. Web.

Gersni, Bernadette. "Ethical Issue Patient Advocacy vs. Patient Autonomy." Personal interview. 24 July 2013.

Jonsen, Albert R., Mark Siegler, and William J. Winslade. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. New York: McGraw-Hill, Health Professions Division, 2006. 

Lawrence, Dana J. "The Four Principles of Biomedical Ethics: A Foundation for Current Bioethical Debate." Journal of Chiropractic Humanities, 2007, https://www.researchgate.net

Lynch, Martin F. "Attachment, Autonomy, and Emotional Reliance: A Multilevel Model." Journal of Counseling & Development, vol. 91, 2013, pp. 301-12.

Mahlin, Margaret. "Individual Patient Advocacy, Collective Responsibility and Activism Within Professional Nursing Associations." Nursing Ethics, vol. 17, no. 2, 2010, pp. 247-54. 

McNaughton, David, and Piers Rawling. "On Defending Deontology." Ratio, vol. 11, no. 1, 1998, pp. 37-54. 

Noureddine, Samar. "Development of the Ethical Dimension in Nursing Theory." International Journal of Nursing Practice, vol. 7, 2001, pp. 2-7. 

Wheat, Kay. "Applying Ethical Principles in Healthcare Practice." British Journal of Nursing No, vol. 18, no. 17, 2009, pp. 1062-063.