Introduction
Ethical dilemmas are integral to nursing practice, which is why it is essential to study them. Every day, nurses make critical decisions that impact patient health and life. Having such a significant responsibility makes it important for nurses to choose options that are in the patient’s best interests. Sometimes the choice is simple; nevertheless, there are also barriers to ethical practice that can be structural or personal. For instance, some nurses experience ethical dilemmas due to impaired communication or inadequacy of treatment prescribed. Others, however, face ethical challenges that involve patients and their beliefs. Patient’s involvement in medical decision-making often creates ethical problems, especially if his or her culture or religion opposes certain methods of treatment.
This essay aims to describe and analyze a clinical situation that involved an ethical dilemma. The chosen clinical situation is the patient’s refusal to proceed with medical treatment due to his religious beliefs. The case exemplifies some essential topics, such as culturally-sensitive care, patient autonomy in decision-making, and the application of ethical theory to practice. The main ethical theory will be applied to the chosen clinical situation in narrative ethics. Reviewing the clinical situation from a theoretical perspective can help in gaining valuable insight into ethical decision-making in nursing.
Clinical Situation
The patient is a 69-year-old white male who was admitted to primary care due to repeated vomiting. Upon examination, it was found that the patient has high blood pressure, fatigue, and increased swelling of the feet, which indicated that he might have kidney disease. Right from the beginning, the patient refused medication for vomiting; however, he accepted hospitalization and further diagnostic tests. The doctors also suspected that the patient is dehydrated due to vomiting, and treated him for dehydration after receiving approval. Blood tests, urine tests, and kidney ultrasound were prescribed by the doctor to evaluate kidney damage and determine the presence of kidney disease. The blood test indicated that the patient had a low content of red blood cells, showing signs of anemia, while the ultrasound and urine tests confirmed chronic kidney disease.
Upon hearing about the diagnosis, the patient appeared to be sad. The doctor explained that, although the disease was not curable, it was possible to control the symptoms, including high blood pressure, fatigue, and nausea. In particular, the doctor noted that a red blood cell transfusion was in order due to the patient’s anemia. However, the patient revealed that he was a Jehovah’s Witness and that his religious beliefs prevented him from receiving a blood transfusion of any sort. Even after the doctor explained the benefits of the procedure and the consequences of leaving anemia untreated, the patient did not agree to the procedure. He explained that his faith was more important to him than his quality of life. I chose not to interfere with the patient’s decision, as I did not have enough knowledge and experience with ethical decision-making at the time. Therefore, the patient only accepted the prescribed medications for high blood pressure and nausea. After the initial symptoms subsided, the patient was released from the hospital.
Ethical Characteristics of the Dilemma
Hamric, Hanson, Tracy, and O’Grady (2014) state that certain characteristics distinguish ethical dilemmas in nursing from other work situations. According to Hamric et al. (2014), “an ethical or moral dilemma occurs when obligations require or appear to require that a person adopt two (or more) alternative actions, but the person cannot carry out all the required alternatives” (p. 328). Thus, ethical dilemmas are defined by the conflict that puts pressure on the moral agent and complicates the decision-making. In the present case, the two conflicting actions were to persuade the patient to accept the blood transfusion and to respect the patient’s beliefs. The moral distress, which is also characteristic of moral dilemmas, resulted from the understanding that the patient’s quality of life could be improved after the treatment. The influence of religion on medical decision-making can often threaten patients’ life and health, which is why it poses significant concerns for nurses and other medical professionals (Coyne, 2015).
Apart from defining the key characteristics of moral dilemmas, Hamric et al. (2014) also list three main types of sources of ethical dilemmas: communication problems, interdisciplinary conflict, or multiple commitments. Communication problems arise when one or more of the parties involved fail to provide a clear and succinct explanation of his or her viewpoint (Hamric et al., 2014). For example, a dispute between the patient and his family regarding treatment options is an example of a communication problem. Interdisciplinary conflict, on the other hand, occurs between different professionals (Hamric et al., 2014). For instance, if two different medical professionals, such as a physician and a surgeon, disagree on the preferred treatment option, it might cause an interdisciplinary conflict leading to an ethical dilemma.
Finally, as nurses often have commitments to multiple parties, including the patient, family, and other medical professionals, they might experience ethical dilemmas resulting from multiple commitments (Hamric et al., 2014). The clinical situation described as a result of impaired communication between the patient and the medical professionals attending to him. Having different cultural or religious backgrounds is among the key barriers to communication reported by patients and medical professionals (Norouzinia, Aghabarari, Shiri, Karimi, & Samami, 2016). Initially, the patient did not mention his religious beliefs upon being admitted to the hospital, which is why the doctor offered an inappropriate treatment method to him. Moreover, the doctor did not provide comprehensive information about the treatment when the patient first started his views, which is why I tried to influence the patient by providing more information.
Ethical Principles
Ethical principles or rules are the aspects of the decision that are taken into account in an ethical dilemma. Hamric et al. (2014) identify several key ethical principles, including autonomy, beneficence, nonmaleficence, justice, and respect for persons. In the present situation, the principles of autonomy, respect for persons, beneficence, and nonmaleficence were the main aspects of the conflict. The decision to release the patient without red blood cell transfusion promoted the ethical principles of autonomy and respect for persons by allowing the patient to make decisions about his treatment and accepting his views. However, it also violated the principles of beneficence and nonmaleficence. The principle of beneficence stresses the importance of promoting positive health outcomes and advocating for the patient’s best interests. Nonmaleficence, on the other hand, includes avoiding harm and actions that could hurt the patient. As the treatment did not target the patient’s anemia, which could be a threat to his further life and health, both of these ethical principles were violated.
Barriers to Ethical Practice
There are four types of barriers to ethical practice, including barriers internal to the nurse, interprofessional barriers, patient-provider barriers, and organizational or environmental barriers (Hamric et al., 2014). In the present situation, three types of barriers were evident. First of all, barriers internal to the nurse, including the lack of ethical knowledge and confidence, affected my decision-making in the clinical situation. I was unsure how to address the patient whose religious beliefs prevented him from obtaining the treatment he needed, which affected my decision to step away instead of persuading the patient to proceed with the treatment.
Another barrier to ethical practice that was evident in the scenario was the difference in cultural and religious backgrounds, which is one of the key patient-provider barriers (Hamric et al., 2014). I had little knowledge and understanding of the patient’s religion and thus was unable to emphasize his views and show compassion. As demonstrated by Hordern (2016) religious and cultural beliefs are often the source of ethical issues as they often contradict the obligations of medical professionals and normal diagnostic or treatment practices. Also, differences in religion and culture prompt for a higher risk of miscommunication, which is a barrier to ethical decision-making (Norouzinia et al., 2016).
Finally, the absence of a clear guideline for culturally-sensitive care in the primary care unit of the hospital was an organizational barrier to ethical practice. As shown by Douglas et al. (2014), creating a distinctive code of conduct or set guidelines for nurses and other medical professionals is a vital factor influencing the implementation of culturally competent care.
Ethical Theory
The present clinical case is rather complex, with a variety of perspectives and viewpoints affecting the outcome. However, the patient’s religious beliefs are the key aspect of the ethical dilemma. Faith is important to many people. Hordern (2016) explains that religion and spirituality often give patients moral strength to overcome the disease or live a fulfilling life with their diagnosis. The importance of faith for the patient has to be taken into account when doctors or nurses make critical treatment decisions. Therefore, narrative ethics would be useful for resolving the case. Narrative ethics emphasizes the importance of the patient’s story in making a difficult decision (Hamric et al., 2014). By applying narrative ethics to the clinical situation, the doctors and nurses would have been able to learn more about the importance of faith for the patient, which could have helped them in making an informed decision.
Reflection
The clinical situation described in the essay is an important example of an ethical dilemma in nursing care. The dilemma was focused on whether or not to insist on red blood cell transfusion when the patient refuses it due to religious reasons. On the one hand, the ANA Code of Ethics requires nurses to act in the patient’s best interests and perform actions necessary for promoting better health outcomes (ANA, 2015). On the other hand, however, the ANA (2015) also stresses the importance of patient advocacy and protecting patient’s rights. The ethical dilemma in the present clinical situation was the result of a conflict between the required treatment actions and the patient’s right to make decisions regarding his health and wellbeing.
Although I decided not to try to persuade the patient to proceed with treatment, the clinical situation made me anxious and sad, and I remember it every time I treat patients from different cultural or religious backgrounds. It is not often that patients refuse treatment due to their cultural or religious beliefs; however, it usually prompts me to think about how to handle the situation correctly to balance patient health outcomes and the patient’s right to autonomy.
Dr. Jean Watson’s theory of human caring science applies to the clinical situation as it emphasizes the need for nurses to respect the patient’s rituals, wishes, and beliefs. The theory also shows that there are multiple paths to knowledge, thus arguing that using evidence-based practices is not the only option available to nurses. The theory promotes the importance of building a patient-provider relationship that is based on mutual trust and understanding, which is essential to provide culturally-sensitive care.
I believe that, if a similar situation arises in my work as a Family Nurse Practitioner, I will be able to approach it as a more insightful and make an informed decision. I would use narrative ethics to make a decision based on the patient’s story. I would also approach the decision-making based on Dr. Jean Watson’s theory of human caring science, thus building a supportive and caring relationship with the patient.
Conclusion
Overall, I think that the purpose of the assignment was to obtain insight into the clinical situation and to re-evaluate it using ethical principles and theories, as well as to develop knowledge of the barriers to ethical practice. Improving my knowledge of ethical dilemmas in nursing care allowed me to see the weaknesses of my approach to the issue and to develop a thorough understanding of what else could be done to resolve the dilemma. This experience can be used to resolve ethical dilemmas and conflicts in my future work, thus improving the quality of care provided to patients.
References
American Nurses Association (ANA). (2015). Code of Ethics with interpretative statements. Silver Spring, MD: ANA.
Coyne, J. A. (2015). Faith healing kills children. Slate Medical Examiner. Web.
Douglas, M. K., Rosenkoetter, M., Pacquiao, D. F., Callister, L. C., Hattar-Pollara, M., Lauderdale, J.,… Purnell, L. (2014). Guidelines for implementing culturally competent nursing care. Journal of Transcultural Nursing, 25(2), 109-121.
Hamric, A. B., Hanson, C. M., Tracy, M. F., O’Grady, E. T. (2014). Advanced Practice Nursing: An integrative approach. Amsterdam, Netherlands: Elsevier Health Sciences.
Hordern, J. (2016). Religion and culture. Medicine, 44(10), 589-592.
Norouzinia, R., Aghabarari, M., Shiri, M., Karimi, M., & Samami, E. (2016). Communication barriers perceived by nurses and patients. Global Journal of Health Science, 8(6), 65-74.