Sally Analysis: Anorexia Nervosa, Ethical Issues - Case Study Example

Sally Case Study: Anorexia Nervosa, Ethical Issues Institution Name Date Sally Case Study: Anorexia Nervosa, Ethical Issues Introduction Treating eating disorders such as anorexia nervosa pose numerous ethical dilemmas. For instance in this case the main ethical issue is whether Sally’s desire not to consent to both the insertion of a PEG tube and to artificial feeding take priority over her deteriorated condition of anorexia nervosa? This essay will discuss whether Sally has legal rights to refuse these procedures and the ethical issues involved. Basically, autonomy plays an important role in Sally’s decision. Autonomy is the key ethical obligation to protect an individual’s right to self-determined choice. The principle of autonomy acknowledges that a competent person has the right of making informed choices without coercion or unjustified influence. According to Wright (2010) autonomy involves the liberty of an individual to have freedom of action as well as freedom of choice and autonomy also involves respecting an individual’s autonomous decisions in spite of believing that another person’s choice is not correct or harmful. As a result, Sally has the liberty of deciding what treatment or procedure to consent to but the principle of autonomy comes under challenge if the patient is not competent to make a rational decision regarding her treatment. However, the complexity with the principle of autonomy is that it is not always easy to determine an individual’s level of competency. For instance in this case perceived irrationalness of Sally is not enough, it should be shown that she does not have the capacity of undertaking rational decision making for her to be considered not have the legal right to refuse the procedures. Anorexia nervosa presents several dilemmas because it is difficult to fathom the stage at which this condition triggers provisions under a Mental Health Act thus overriding matters of consent basing on treatment being the patient’s best interests. Therefore, in this case it would be important to establish the stage that a patient becomes cognitively incompetent whereby if the patient gives an Advanced Directive when competent whether this can be overridden or is the patient supposed to be allowed to die because of not eating owing to this being their choice (Silber, 2011). Nonetheless, even though the skills of people with eating disorders are congruent with what is necessary for legal capacity tests, and thus it can be presumed that they have the legal rights to make decisions without interference of other people, this does not involve the role pathology and emotions play during decision making. According to Silber (2011), patients with anorexia nervosa although they do not have problems with their cognitive functioning they perform poorly than people without such an eating disorder during decision-making tests. In addition, a study conducted by Uher on the ventromedial prefrontal cortex in patients with eating disorders indicated impairment. Consequently, autonomy in patients with anorexia nervosa is problematic since such patients have a pseudo-autonomous position whereby they give an impression that they do not need other people since they are illogically placing themselves at risk in a manner that calls for rescue (Silber, 2011). Generally, patients with eating disorders such as anorexia nervosa in most cases a lack of control or empowerment in their lives and thus Sally lacks the competence to make rational decisions and thus she does not have the legal right to refuse the medical procedures. In addition, criteria to determine capacity to consent or refuse treatment consist of ability to understand information, the ability to believe it, as well as the ability to weigh the information and make a rational decision basing on the information. Competence refers to the legal conception of capacity. Practically, competence in mental health professionals also includes other aspects like the ability of a person to apply the knowhow in their own situation, the consistence of decisions with time, along with the value systems of the individual. Patients with eating disorders might continue having effective functional insight and decision making capacity in other aspects of their lives but may have severe impairment in their capacity allied to the eating disorder (Wright, 2010). Therefore, even though Sally may be having highly functional insight as well as decision-making capacity in other areas, her capacity to make a decision regarding her anorexia nervosa condition may be impaired and thus she does not have the legal rights to refuse both forms of treatment. The concept of beneficence involves doing good for others through contribution of and promotion of general human health and welfare and doing the best interests of the patient (Martin & Curtis, 2010). Since Sally is refusing the necessary treatment, her autonomy and the principle of beneficence are in conflict. Refusing treatment for patients with anorexia nervosa is a common characteristic and thus the health care is faced with the predicament of providing care to the affected persons in order to do good to the patient. The principle of beneficence calls for the healthcare provider to act in the benefit of the patient which means that they should promote good and prevent harm. Therefore, in case a patient makes a decision that the healthcare provider thinks it is not beneficial to the patient; the nurse can ignore the wishes of the patient (Lakhan, 2009). Accordingly, Sally is refusing treatment (artificial nutrition) which is beneficial to her health yet her condition has deteriorated so much. Without the treatment using the artificial nutrition Sally’s condition could worsen and with the treatment her condition is bound to improve and thus the benefits of acting beneficently should be weighed against the disadvantages of refusing to respect Sally’s autonomy. In this case, there are more benefits to Sally’s autonomy being overruled and thus the healthcare provider has the responsibility of ensuring that Sally gets safe, effective and ethical care and thus considering the principle of beneficence Sally does not have the legal right the treatment. The principle of nonmaleficence requires healthcare providers not to intentionally create unnecessary harm to the patient; either though acts of commission or omission. Principally, a healthcare provider is considered as being negligent for inflicting a careless or irrational risk of harm on the patient. Basically, providing suitable standard of care that reduces or gets rid of the risk of harm is held by moral convictions and the societal laws as well. This means that the healthcare providers can be morally and lawfully blameworthy if they fail to meet the principles of due care. The principle of nonmaleficence stipulates that medical care should involve competence (Lakhan, 2009). When taking care of patients such as Sally, there are some circumstances where some form of harms are unavoidable and hence healthcare providers are usually morally bound to select the lesser of the two evils, although it is possible to determine the lesser evil according to the situation. Do no harm to the patient (Martin & Curtis, 2010). In this case, Sally is refusing to consent to the insertion of PEG tube as well as to artificial feeding. Probably, these forms of treatment are uncomfortable to Sally and also she is not okay with this form of treatment and this is the only form of harm that is present here. On the contrary, if Sally is not given the forms of treatment she is refusing, her condition is bound to further worsen. In this case, the medical practitioners are supposed to take the course of action that will result to the least harm. Seemingly, artificial feeding of the patient and insertion of the PEG tube might make Sally uncomfortable and such, but Sally refusing to be treated is likely to result to greater harm. Therefore, treatment of Sally should take preference over her wishes because that is the lesser of the two resulting harms which means that Sally does not have the legal right to refuse the treatment basing on the principle of nonmaleficence (Armstrong, 2007). Furthermore, since the concept of nonmaleficence upholds the Hippocratic Oath to “above all do not harm”, there are active and passive types of likely harms in Sally’s case. Generally, patients like Sally with eating disorders such as anorexia nervosa can be challenging and create strong counter-transference responses. In this case, an active form of harm would be unsuitably terminating treatment or abandoning Sally and stir up feelings of rejection, incompetence or powerlessness. Nonmaleficence calls for the medical practitioners to work within areas of competence and therefore provision of artificial feeding to Sally is the likely form of action that would alleviate the harm (Wright, 2010). Utilitarianism ethical theory stipulates that the right moral response is directly related to the outcome of the action. The value of an action is determined by the degree that the action produces happiness or welfare and thus no act is wrong or right because only the outcome of the action is valuable. All the likely outcomes of all the actions should be considered and the action likely to be the most beneficial (producing highest level of happiness) and producing the minimum unhappiness is the best (Steven, 2009). In this case, utilitarianism theory would perhaps consider treatment of Sally through artificial feeding and insertion of the PEG tube justified. This is because among the two choices which include artificial feeding of Sally using the PEG tube and not providing this form of treatment, the former action has the likelihood of producing the highest level of happiness because it will in the long-run promote Sally’s wellbeing unlike the latter action. What’s more, artificial feeding of the patient is likely to have minimal risks which include going against the Sally’s wishes and perhaps the associated discomfort as compared to not providing artificial feeding to the patient, which has the likelihood of bringing minimal unhappiness because there is a possibility of Sally’s condition deteriorating further, which is worse. Accordingly, artificial feeding of Sally is justified since it produces the greatest wellbeing and thus Sally does not have the right to refuse the treatment as per utilitarianism ethical theory (Steven, 2009). Utilitarianism ethical theory suggests that the action taken should produce the greatest happiness to the highest number of people. Therefore, even though not feeding the Sally artificially will make her happy because her wishes will be satisfied, utilitarianism is about the total human happiness, and not the patient’s happiness. The negative effect of the people around the patient, for instance the family members, friends and also healthcare practitioners outweigh the benefit to the patient (Meslin, et.al, 2009). Virtue theory entails an individual of outstanding character doing the correct thing. The important thing in virtue theory is that a person cultivates good character for him/her to be a person who can always do what is good and right. In this case, Sally does not have the legal rights of refusing treatment because she is choosing what is not good and the right thing to do is to have artificial feeding. The virtue ethics theory justifies the healthcare providers’ action of feeding her artificially despite Sally’s refusal to treatment (Lakhan, 2009). Specifically, patients with anorexia nervosa suffer from the effects of starvation and consequently might be struggling with impaired reasoning and cognitive capabilities. A person like Sally might be experiencing cerebral pseudoatrophy and/or biochemical changes due to nutritional deficiencies. Within all situations allied to starvation, a physical threshold may occur where an individual is no longer in a position to think rationally due to chemical changes within the body resulting from starvation and malnutrition as well (Trueman, 2013). Consequently, it is appropriate for an agreement to be made with Sally during the onset of her treatment but if she does not give consent to the treatment her right to autonomy should be overridden by the fact that the effects of starvation might have affected her cognitive abilities and impaired her reasoning and thus her right to refuse the treatment should be overridden (Lakhan, 2009). Conclusion Sally has no legal right to refuse the treatment because although the skills of people with eating disorders are congruent with what is necessary for legal capacity tests, this does not involve the role pathology and emotions play during decision making. Anorexia nervosa might also have affected her cognitive abilities as well as her reasoning capability and thus she can be considered as not having the capability to make rational decisions. Additionally, a healthcare provider has the prima facie duty of benefiting the patient as well as avoiding harming the patient. In this case the healthcare providers are supposed to balance the demands of healthcare ethical principles by establishing which has more weight in the given case. Normally, prima facie duties are always obligatory except when they conflict with more stringent responsibilities. Therefore, in deciding to feed Sally artificially despite Sally having expressed otherwise, precedence will be given to the prima facie duty of avoiding harm and providing medical benefit. Finally, according to the utilitarianism theory, the action of artificial feeding is justified because it is the moral action likely to produce the utmost good for the greatest number. References Armstrong, A. (2007). Nursing Ethics: A Virtue-Based Approach. Palgrave: Macmillan. Lakhan, SE. (2009). "Time for a unified approach to medical ethics". Philosophy, Ethics, and Humanities in Medicine.Vol. 3/13. Martin, B, & Curtis, J. (2010). Ethics in nursing: cases, principles, and reasoning. Oxford: Oxford. University Press. Meslin, E, et.al. (2009). Helsinki discords: FDA, ethics, and international drug trials. The Lancet. Vol. 13/4. Steven, E. (2009). Inclusion: The Politics of Difference in Medical Research. Chicago: University of Chicago Press. Silber, T. (2011). Treatment of Anorexia Nervosa against the Patient’s Will: Ethical Considerations. Adolesc Med. Vol. 022/ 283–288. Wright, M. (2010).  Ethical dilemmas in treating clients with eating disorders: A review and application of an integrative ethical decision-making model. European Eating Disorders Review. Vol.18/6.  Trueman, S. (2013). Anorexics Force Legal Decision. Retrieved on 16th April 2013. . Read More