Nurses are a very essential part of the hospital setup and as such are required in many ways to assist the patient. “Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health and to alleviate suffering” (ICN, 2006). Being human beings, nurses may apply their own subjective opinions in dealing with patients. This, therefore, means that their conduct in their workplace must be regulated by certain codes and ethics or medical ethos. This paper delves into the ethical concepts involved in practicing medicine-related fields and particularly nursing in a bid to understand the theories involved, the subsequent principles, the elements of confidentiality and reasonable limits and lastly the ethical decision-making process employed by a nurse to resolve various ethical conflicts that arise in consent, confidentiality and cultural practices.
Before looking at the ethical theories, these are the basic codes a nurse is to live by when working with patients according to the International Council of Nurses (ICN):
- The responsibility of confidentiality and autonomy to the patient and responsibility to the environment.
- The responsibility to the practice itself is to exercise logic, leadership and adeptness in utilizing innovative technological advancements and ensure their safety in dealing with the patients.
- In respect to the profession, the nurse ensures equitable and favorable working conditions for the fellow nurses and ensures that high acceptable standards of service delivery are met. Cooperation with fellow workers is also a requirement.
The following are some common ethical theories as seen in Med India:
- Natural Law has its basis on the postulations of Aristotle. It states that man should live life in accordance with his/ her inherent human nature; his conscience is his guide (Med India, 2010).
- Utilitarianism, which is the most common and is sometimes referred to as consequentialism or theology. It simply calls for achieving the greatest good for the majority of the people. It applies where governments or people try to attain a social purpose to better the lives of everyone involve (Med India, 2010).
- Deontology is guided by the view that the most important aspects of human life are guided by moral rules which cannot be broken.e.g. The Decalogue (Med India, 2010).
- Virtue Theory posits the universality of certain virtues e.g. wisdom and charity (Med India, 2010).
From these theories spring ethical principles which are discussed below:
Autonomy. It is the principle of individual freedom. A patient should be free to make his/ her own decisions. This, therefore, calls for the medical team to equip the patient with information about their conditions so that they can make an informed choice on treatments and it eliminates the element of paternalism which has been existing among doctors and nurses who made choices on behalf of the patient. It calls for honesty with the patient and respect for patients’ values. This is important to nursing as it allows the patient to become more knowledgeable on certain ailments and it gives the patient more control and authority over their life decisions. For example, a person suffering from leukemia needs to make a lot of decisions about treatments and their quality of life. A nurse should be ready to respect the patient’s wish not to explore experimental treatments if the chemotherapy has proved to be painful, arduous and fruitless. It is however his/ her duty to at least present these options and try to persuade the patient.
Beneficence, which simply means doing good. Terminally ill patients need a lot of moral support and comfort in their last days. A nurse is crucial to this principle because they are the ones who take care of the patient most of the time and are usually at their bedside. It is also the main reason for entering the medical profession. for example, a nurse may choose to play a routine game of cards with a person suffering from lupus (especially if they have no family) to give the patient hope to fight every day to prolong their life and give the patient some form of rejuvenation.
Nonmaleficence entails the basic medical student’s credo, “first, do no harm.” It involves not causing the patient any harm, preventing any harm to the patient, and eliminating any potentially harmful situations. A nurse should always make sure that their own personal hygiene and that of the hospital is excellent. For example, the staff infection spreads in hospitals because of the inadequacies in quarantine and hygienic standards.
Confidentiality requires that the nurse keeps the records of the patient private even after the death of the patient and that the nurse avoids sharing such information with other staff (GDC, 2005). This helps in building a rapport with the patient and a relationship of mutual trust such that the patient does not hesitate to give all the information useful and relevant to the condition. For example, an AIDS patient requires that patient confidentiality be upheld especially regarding the mode through which he/ she became infected. Regarding the testing for HIV, some patients may not want to get tested if the confidentiality of the results is not assured.
Personal Integrity, which means being principled and having your moral standards in carrying out professional work. The nurse may be faced with a situation where the patient is having an extra-marital affair and is infected with gonorrhea. The nurse may feel compelled to tell the wife so she can protect herself even if it might break confidentiality. The nurse can therefore try to convince the patient to come clean so that the spouse can be tested and get treatment. This therefore brings me to the aspect of disclosure for special cases where another person’s health is at risk or in the interest of public health (quarantines) which will be discussed later on.
Distributive Justice refers to the fairness in the allocation of time, resources and attention to different patients. It calls for objectivity. A nurse must put all personal prejudices aside and deal with the patients equally. For example, he/ she should not avoid a grumpy and difficult patient as this may be the only way that they know how to appeal for attention.
Ethical codes and oaths as discussed earlier give a guideline into how to treat patients among other things. These are important in regulating rules of behavior that can be applied to nurses everywhere. For example, the Hippocratic oath promises to preserve human life, which is a universal necessity (Tasmania Department of Health, 2001).
The principle of confidentiality has seen discussed above but how does it tie into reasonable limits? Reasonable limits are the circumstances where the government can infringe upon or limit its citizens’ Charter Rights for purposes of national interest e.g. limiting free speech when the message is racist and hateful (Van Rassel, 2004).
These are the elements of determining reasonable limits: the law should be proportionate to the objective of exercising reasonable limits. The law must be sufficiently justifiable to warrant exercising these limits, the law should be adequately and logically connected to the objective of reasonable limits and lastly, the law should not infringe more than is necessary to achieve objective of reasonable limits (Hiebert, 1990).
Confidentiality can be broken in view of public interest or to save another life. Say a child, a 16-year-old girl (the patient) needs an urgent abortion to save her life but she refuses because she fears that her parents will know about her sexual activities thus the nurse needs consent from the parents. The child’s confidentiality may be broken to seek consent from the parents regardless of the girl’s protestations of her parents knowing about her sexual activity (He Academy, n.d.).
The above 4 elements of reasonable limits justify breaking confidentiality only when all other methods have been used to try and convince the patient to get treatment and this fails, the nurse can resort to legal measures to seek a resolution. The case of Mrs. Z may require breaking confidentiality so as to save her life since she refuses to return to get treatment.
The example of the young attorney who had drug-resistant TB and wanted to fly for his honeymoon is where confidentiality can be broken and reasonable limits to his movement are applicable. The laws are proportionate in that they do not call for restricted movement and not incarceration or indefinite restriction and they do not infringe so much to the extent that one feels like a felon (General Dental Council, 2005).
There may be conflicts in the ethical principles such that as much as you want to stick to confidentiality, the nurse is forced to break this principle and may even take over autonomy. For example by the nurse choosing to disclose details to Dr.J., the nurse is bringing up a conflict between patient confidentiality and the respect for her wishes to keep her medical information private. In so doing, Mrs. Z loses the authority to control the methods of treatment and when she wants to employ which method. Mrs.Z now has to reveal the details of her condition and will have to come into the hospital to seek her medical options as spelled out by the nurse and Dr. F regardless of the probability that she did not want to seek any medical resolution in the first place.
The ethical theory of virtue supports breaking confidentiality as applied to Mrs. Z’s case. The virtue of wisdom and the preservation of human life which touches on deontology calls for a rationale examination of the situation so that the nurse and Dr. F can decide whether it would be appropriate to break the patient confidentiality and discuss details of the patient’s health with Dr. J and more so her family. What is more prudent in this case; let Mrs. Z continue refusing treatment or try to convince her to pursue treatment through involving a second opinion in Dr. J or her own family’s input (Encyclopedia of surgery, n.d).
Culture influences our values through socialization and the reinforcement of societal norms through social institutions. Our values are our sense of right and wrong Since nursing is universal it becomes important for the nurse to acknowledge and respect the vast and varied belief systems of their patients e.g. Jehovah witnesses cannot take blood transfusions thus bringing the ethical conflict of saving their life or respecting their religion and seeking the next best alternative (Ludwick, 2000).
In a 2004 National Ethics Teleconference, Joint Commission for Accreditation of Healthcare Organizations (JCAHO) stressed that healthcare institutions are required to “respect the culture and rights of patients” by “respecting patient autonomy and shared decision-making” (JCAHO, 2004, p3). This then puts friction between culture and healthcare delivery as exemplified in the case study of Mrs. Z.
In the case study of the Z family, the cultural values of full submission and reverence to the man bring cultural differences into view. For the practitioners(nurse and Dr. F), the lack of openness of Mrs. Z about her medical problem to her husband because of fear or misguided sense of shame puts the principle of autonomy into play. Will the medical staff respect her wishes not to seek treatment and to continue concealing details of her condition or will they instead invoke the reasonable limits in sharing information with Dr. J and breaking patient confidentiality?
For the Z family, there is no confidentiality required when dealing with medical records. According to their values, Mrs.Z’s family was permitted to be in the room during her examinations but was allowed to be in the room alone because her health care providers were all female. On the other hand, the nurse and doctor are required to keep the patient confidentiality and privacy regardless of the patient’s gender. However, as seen in the case study, this may require that the providers break the confidentiality and coerce Mrs. Z into seeking her family’s input in making such a decision.
With reference to the case of the Z family, there are 2 interventions that can help reduce or resolve the ethical conflict of breaking confidentiality. One, share information with Dr. J , which is common in this day and age of electronic records. Two, call in Mr. Z and his mother and disclose the details of the biopsy results. Then they can try to persuade Mrs. Z that it would be prudent for her to come into the office and explore the options available to her before her condition deteriorates to a point where a mastectomy or even death awaits her.
By discussing the details of the condition with Dr. J, the nurse and doctor may convince Mrs. Z of the urgency of coming in to discuss options and committing to a treatment plan by giving her second opinion. Sometimes patients do not understand the gravity of the situation or are not fully convinced of the reality or existence of their condition (especially when it comes to terminal illnesses such as cancer) such that they form a defense mechanism of denial. This will also help convince Mrs. Z that her situation is dire and must be treated as soon as possible.
“Ethical decision making is the application of the processes and theories of moral philosophy to a ‘real’ situation” (“Tasmania Department of Health”, 2001).
The following is a decision-making model that may help in the situation of the Z family: Authority, Logic, Precedent and Emotion (American Nurses Association, 2004).
Authority
It calls for seeking the guidance of a higher authority in dealing with a certain matter. It may involve discussing the matter with a superior, the laws, and parents (if the case involves a minor) and of God if the person is pious and believes in the existence of a higher deity who is above reproach. This is very helpful when the decision that needs to be made is very complex and morally challenging. This applies to situations where ethics committees may be called as the superior authority to the nurse and doctor. In the case of Mrs.Z, the nurse and doctor may seek the input of the Chief of staff in the hospital and of an ethics committee if it exists. The law may also guide the decision of breaking confidentiality or giving consent where the courts may be sought to temporarily take over the decision-making powers over the patient (Stauch, Wheat & Tingle, 1998).
“Prima facie every adult has the right and capacity to decide whether or not he will accept medical treatment… Furthermore, it matters not whether the reasons for the refusal were rational or irrational, unknown or even non-existent… However, the presumption of capacity to decide which stems from the fact that the patient is an adult, is rebuttable” (“Tasmania Department of Health”, 2001).
Logic
This entails exercising rational choices available such that the most appropriate and future-oriented decision is exercised. In the case of Mrs. Z, the future repercussions of refusing treatment must be examined. To the nurse, it seems more logical to break confidentiality of the patient for the moment than to let her health deteriorate because of codes and autonomy principles.
Precedent
The experience and history of the past guide this decision-making process by reflecting on the outcomes of past cases where confidentiality was broken (or not) and the consequences of each approach. Mrs. Z’s case requires that the nurse looks at cases involving the same cultural values and health conditions. In most cases it is mired dire to respect culture over the wellbeing and health of the patient. For example the case of a young Jehovah’s Witness girl requiring a transfusion in which the parents and boyfriend sought a court order to consent to the transfusion.
Emotion
This refers to the nurse’s intuition and personal feelings regarding the decision. The nurse in the case study should exercise her conscience in deciding whether to share information with Dr. J and the Z family because Mrs.Z might die if she continues to refuse treatment.
In conclusion, issues related to nurses’ ethical code and principles have been explored in detail about the case study of the Z family. We began by outlining the code according to the ICN containing The 4 elements of relation to the profession, colleagues, the practice and the patient. The ethical theories of natural law, deontology, virtue and utilitarianism were explored and related to nursing practice giving an example of why these theories are important to nursing. The principle of confidentiality is also discussed about reasonable limits set on charter rights. How the elements of confidentiality and reasonable limits relate is also explored.
The rationality behind breaking confidentiality is also discussed in relation to saving or preserving lives and given public health in the case of quarantines. Conflicts in ethical principles usually arise and it becomes necessary to resolve them. This is discussed in relation to autonomy and confidentiality.
These principles are linked to the case study of the Z family and in relation to how it would be in conflict with the patient confidentiality of Mrs. Z. The ethical theory of virtue and deontology explain or support the decision to break the confidentiality of the patient by relating virtues and unbreakable laws of the Ten Commandments.
The influence of culture and how it relates to both the nurses and the patient are explored and nursing interventions to reducing and resolving ethical conflicts are espoused.
The ethical theory of authority, logic, precedent and emotion define the situation. Identify the values or moral beliefs, the choice of loyalties that is, to the patient or to the codes of nursing practice and the principles regarding what is morally right and follows the Hippocratic oath of preserving human rights are explored. Its relation to the case of the Z family is also discussed. Therefore, it becomes evident that nurses require an ethical code in dealing with patients especially regarding confidentiality. It is a task that is daunting and requires not only our humanity but also the laws that are prescribed about human life and rights to privacy. The quote below summarizes the critical nature of confidentiality although it still remains a grey area in ethical practice and principles.
“Both the ethical and the legal principles of confidentiality are rooted in a set of values regarding the relationship between caregiver and patient. It is essential that a patient trust a caregiver so that a warm and accepting relationship may develop; this is particularly true in a mental health treatment” (Encyclopedia of Nursing and Allied Health, n.d).
Reference List
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