Ethical Conundrums in Clinical Nursing

Modern nurses are essential members of the healthcare team. Nurses are obliged to understand and follow the principles of biomedical ethics as well as professional ethics particular to the art of nursing practice. The ultimate aim of healthcare is the health of the patient, that is each provider’s primary concern the telos of the activity (Delap, 2008). Toward that end, nurses are challenged in resolving moral conundrums as they arise in clinical practice. Therefore, nurses should have understanding and training in the theoretical foundation of the principles of healthcare as well as a practical theory to apply these principles to nursing practice (Callahan, 1998, ANA, 2001, Butts, 2005, Gastmans, 2002).

There are eight principles for healthcare: Autonomy, nonmaleficence, beneficence, justice, privacy, confidentiality, veracity, and fidelity (Beauchamp, 2001, Delap, 2008). Autonomy is the idea that the patient is the ultimate decider of their own benefit. The patient’s right to make their own healthcare decisions is paramount. Justice is equity in the healthcare system. Privacy and confidentiality are essential to the sanctity of the helping and healing relationship. Veracity is honesty and the courage to advocate for what is right for the patient and the profession in the face of opposition. Fidelity is loyalty to the community, the profession, and the patient. Challenges that nurses will face include concerns of valid informed consent based on understanding patient comprehension (Callahan, 1988, Delap, 2008). It is the nurse’s responsibility to ensure that they are benefiting the patient above all else. Beneficence is a measure of ensuring that patients understand their medical conditions and that treatment provided is to help the patient. This is required to obtain informed consent and incorporates fidelity and veracity (Beauchamp, 2001, Delap, 2008). Fidelity and veracity are demands from society on the practitioner. As trusted professionals, nurses have a public trust with skills most individuals do not have. Nurses are therefore obligated to be thorough and honest (veracious) with the primary goal of healthcare as the motivation for the nurse (fidelity) (Beauchamp, 2001, Barbison, 1997, ANA, 2001). Nonmaleficence is not necessarily the opposite of beneficence. Although to do no harm is a healthcare mantra, nonmaleficence includes consideration of when not to intervene is the best course of action, distinguishing the difference between killing and letting die, and respecting DNR orders. For example, a nurse could also violate fidelity and veracity by failing to commit to the duty based ethical theory (deontology) or reflective moral practice of clinical decision making (teleology). (Beauchamp, 2001, Delap, 2008). Cases of nurses not following the principles for the profession and the healing activity erode the public trust in the profession. 

Confidentiality is the moral principle of protecting the privacy of the patient in the healthcare relationship. The patient consents to the provider to obtain medical information through words and through examination. This information is essential for the effective treatment of the patient and the patient expects that information will be held confidential. Justification for the rules to protect confidentiality, according to Beauchamp, include the following arguments; consequence-based, rights-based autonomy and privacy, and fidelity based (2001, 306-309). These are the reasonable limits of the expectation of privacy from the patient in submitting medical information to the provider.  

Consequentialists arguments for the breach of confidentiality are elucidated in the Tarasoff case. In this case the mental health provider had credible belief that his patient was both capable and intended to harm another person. The provider reported his concern, but that information was mishandled which ultimately led to the murder of Tarasoff.  The California Supreme Court ruled that the healthcare provider is obligated to society at large to breach confidentiality when the health and safety of another is at stake. Essentially, that there is a negative consequence for both the patient, and a third party (Beauchamp, 2001). The justification for maintaining confidentiality was the fear that breaching confidentiality, especially in a mental health setting, would have a chilling effect on the providers ability to effectively treat patients because the patient would be reticent to be forthright with the provider. The principles supporting this argument include autonomy, privacy, and fidelity. Autonomy and privacy are self-justifying principles. Fidelity includes obligations to the profession, patient, and the community. 

Justification for the breach of confidentiality, and breaking physicians ethics,  is grounded in the notion that a third party will be harmed if the information is not released. However, some legal requirements bind the provider to release certain information for the benefit of public health. This includes the requirement to report gunshot wounds and certain venereal diseases. Conflicts on justification for the breach of confidentiality continue as more information is digitized and in the area of genetic information.   

The medical concerns in this case is that Mrs. Z is choosing to not treat, nor even consider discussing treating her cancer with her provider nor her family. A patient’s right to privacy can only be violated with their consent or when there is a coherent justified specification to the violate the principle (Beauchamp, 2001 384). A coherent justified specification occurs when greater harm is expected by deontologically adhering to the ethical principle without consideration of the utility or consequences of maintaining confidentiality.  In this case, it is the patient’s choice what she tells her family, this is the notion of autonomy and must also be respected. Mr. Z attempted to engage a friend, Dr. J, to use his privileged status as a physician to gain access to the records of someone who is not his patient. The nurse, working for Dr. F, does not respond to the request without consulting with Dr. F. 

Dr. F and the nurse are only authorized to release Mrs. Z’s medical information with the permission of the patient. Unless there is a serious threat of third-party harm, law empowering Dr. F to release this information, or a serious impairment to Mrs. Z’s health where the only rational action is to release the information, then the privacy of Mrs. Z’s must be respected. 

In the case of Mrs. Z, it would help the provider in resolving the ethical conflict to ascertain from Mrs. Z that she understands the medical consequences of not seeking treatment and not sharing her health information with her family. As presented, this case does not provide a justification for breaching Mrs. Z’s confidentiality against her expressed wishes. However, the provider is responsible to fully discuss the consequences of this decision with her patient. Dr. F and her nurse may encourage Mrs. Z to discuss options with her, but based on this information, it is assumed that Mrs. Z is competent. 

Cultures often influence healthcare decisions and cultural aspects must always be taken into account when making moral decisions in the clinical setting (Jonsen et al. 2002, Barbison, 1997). However, regardless of the cultural mores of a family does not given them privileged access to violate the autonomy of Mrs. Z. Understanding this cultural dynamic is important to the healthcare team as a way of ensuring that Mrs. Z is making sound medical decisions.  

Sometimes Evidence-Based Practice (EBP) and the code of ethics fails to make sense for the benefit of the patient. Also, there may be disagreement among the healthcare team providing care. Ultimately, the nurse is singularly responsible for their own personal actions regardless of pressure for other sources. Cognitively resolving moral problems in nursing requires an understanding of the ethical principles of healthcare and nursing generally (Fry & Redman, 2000). Considerations of methods for resolving moral conflict in nursing is desired by Fry and includes suggestions for modeling clinical decision making around various caring models already inherent in nursing practice (Fry, 1989). 

Jonsen et al. outlines a four-box method for ethical evaluations. The four boxes in this method include: Medical information, patient preferences, quality of life, and contextual features (principles of loyalty and fairness). Using this method, the nurse can sort and order the various factors influencing the clinical ethical decision starting with what is within the realm of the nursing practice. The next three boxes evaluate the patient’s preferences, and including this information assures that notions of patient preferences and cultural influences are evaluated. Contextual features are those that extend beyond the nurse-patient relationship. These are the external influences including the hospital, insurance, or other sources should be considered in providing the best care for the patient (Jonsen et al. 1997). 

Applying the four-box model to the case of Mrs. Z, it is identified in the first box that medicine can treat her condition. However, per box to, the patient has declined treatment. Considering her diagnosis, the quality of her life is going to be affected whether in treatment or the natural course of the disease. This is where the patient asserts their preferences and the healthcare team must only undertake the nursing and medical interventions that will benefit the quality of life for Mrs. Z. For this case, the contextual features include the consideration of her family as a third-party influencing Mrs. Z’s decisions. Ranking the order of priority for Mrs. Z’s case using this method would place in order of importance; patient preference, quality of life, medical/nursing indications, and contextual features. By ordering it this way, the nurse and Dr. F are relieved of any further interventions because what they have already done is in accord with the patient’s best interests. Further, the medical/nursing indications are not valid because the patient doesn’t want them. The contextual features and potential pressures from the third party are insufficient to justify the breach of confidentiality. 

This method is useful in ensuring that all the relevant particulars are ascertained in the nursing assessment. It is then up to the nurse and the healthcare team to identify which principles apply to this particular patient. In most institutions there are clinical ethical consultations and ethics committees that evaluate challenges that arise in healthcare. The nurse may access the collaboration with colleagues or working with clinical ethicists as a second intervention. There is a point in the nursing assessment where there is no more information to gather, in these instances a healthcare decision becomes ethical rather than medical (Delap, 2008).

Nurses must resist the temptation to hide behind physicians or policy and focus on the best practices to the advancement of the nursing profession and, more importantly, the best outcome for this patient. The best course of action is to respect the autonomy of a patient like Mrs. Z in the case presented. There is no evidence to support Dr. F or the nurse to intervene in any other way. Mrs. Z has decided that the best course of action for her health is to not treat her cancer. It is her right and it is the obligation of nursing and medicine to respect that expression of rights. This is rooted in the ethical principles of veracity (honesty) and fidelity (loyalty) to the ethical principles themselves as well as the profession itself. 

References

Barbison, J. (1997). Nursing Ethics: a principle-based approach. Journal of Medical Ethics, 23(1), 59.

Beauchamp, T. L., & Childress, J. F. (2001). Principles of biomedical ethics (5th ed.). Oxford: Oxford University Press.

Butts, J. B., & Rich, K. (2005). Nursing ethics: across the curriculum and into practice. Sudbury, Mass.: Jones and Bartlett.

Callahan, J. C. (1988). Ethical issues in professional life. New York: Oxford University Press.

Code of ethics for nurses with interpretive statements. (2001). Washington, D.C.: American Nurses Association.

Delap, T. (2008). A Doctor's Conscience Conventional and Reflective Morality in Clinical Decision Making. Saarbrucken: VDM Verlag Dr. Muller.

Fry, S. (1989). Toward a theory of nursing ethics. Advances in Nursing Science , 11(4), 9-22.

Gastmans, C. (2002). A fundamental ethical approach to nursing: some proposals for ethics education. Nursing Ethics, 9(5), 494-507. Retrieved April 5, 2013, from http://nej.sagepub.com/content/9/5/494.short

Jonsen, A. R., Siegler, M., & Winslade, W. J. (2002). Clinical ethics: a practical approach to ethical decisions in clinical medicine (5th ed.). New York: McGraw Hill, Medical Pub. Division.

Redman, B., & Fry, S. (2000). Nurses' ethical conflicts: what is really known about them?. Nursing Ethics, 7(4), 360-386. Retrieved April 4, 2013, from http://nej.sagepub.com/content/7/4/360.short