Ethical Dilemma: John in the Car - Case Study Example

The Ethics of John in his Car Nursing often finds itself confronted with an ethical dilemma. Those dilemma's when not solved often drive the nurse to do something else and leave nursing. As early as 1961 Ida Jean Orlando wrote the theory of Nursing Process in which she said, "the purpose of nursing is to supply the help a patient requires in order for his needs to be met (Schmieding, 2002). She felt the behavior of the nurse in reaction to the patient's need was the nursing process. She believed that nursing was caring. Carol Gilligan believed that nursing has a different voice in ethics and that that voice is seldom heard. That voice is about caring and benevolence. The definition of benevolence is to maximize the overall good, to do no harm, and to allow an individual his liberty (Bandman, 2000). Carol Gilligan as well as Ida Jean Orlando has influenced much of what nursing is and in both cases, nursing is about caring. Introduction Carol Gilligan as well as many of the other feminist theorists propose that traditional moral theory, principle, practice and policy " are deficient to the degree they lack, ignore, trivialize, or demonize values and virtues that are culturally associated with women " (Belnap, 2000). Although Gilligan admits that all women and all men do not speak only the values of care or justice respectively, most women do speak in the language of care (Monteverde, 2009) Most nurses at this point are women and they also speak the language of care as does their nursing philosophy. That voice is often silenced however by the system and those that work in it. The system proposes that ethics come from a group understanding in rendering an ethical value. Carol Gilligan, however would say that ethics is about the individual. This paper will use Carol Gilligan's theory of ethics in the ethical dilemma created by John in his car. Case Overview John was a 48 year old male patient with diabetes and early renal disease. He presently lives in his pick up truck and has the independent or stubborn point of view that he would choose to live there versus low income housing. John has had diabetes for some time and for most of his life was able to take care of himself. He worked for the local chemical plant and made an average salary for the area and had insurance benefits. He always felt his was doing pretty well, living in a middle class neighborhood with his wife and two kids. He took his medication and tried to exercise and eat right but his life was pretty hectic. He bought a brand new pick up truck just last year. The local chemical plant closed about 6 months ago and with it went John's job. He has not really been able to find anything else with insurance. His wife left and went back east to live with her parents who were elderly and needed help and they were losing their home here so she felt it was the best thing to do for the kids. John stayed on hoping his job might come back. When he lost the house, he just moved the important stuff into his truck, though the local ordinances do not allow living in a vehicle, after all he was a man alone and did not need much. He couldn't buy his medication and meals were whatever was being served at the soup kitchen. Those are good meals he says but they do not meet his diabetic needs very well. He could not believe it but in order to get help from Medicaid, he had to have a mailing address. He noticed he was getting a sore on his leg and he did call his doctor but he no longer has insurance and because of that, his physician would not see him. He has seen that physician for 10 years and though he tried, he could not get in to see another physician. He did not know about the indigent clinic. He went to the local drug store and got some things to try to keep his wound clean, but it continued to get worse. He decided he best go to the hospital emergency room which he did. He was admitted to the hospital and treated with IV antibiotics and dressing changes. Once the infection was gone a case manager came to see him and they talked about his inability to pay for his care. He needed regular care or he would soon need dialysis. She could get him into a low income apartment for now but he could not keep his truck, he would have to sell that as part of his fees. He did not feel he could do that and chose to be discharged to his truck. Before he leaves the case manager makes an appointment for him to be seen at the local clinic. He arrives and the nurse is faced with a patient that needs to be readmitted to the hospital for a badly infected leg. He later loses his leg and ends up on dialysis at a very early age. As noted prior in John's case, further investigation into the case told us that this patient was discharged to his truck because there were not other option since John had refused low income housing and he did not have adequate dressings to care for his wound. "He probably had needed to be in the hospital longer but being overwhelmed as usual, patients do not stay as long as they once did and John does not want to go to low income housing, as we noted. The nurse is placed in a position of having to do what the institution requires of her, putting away her caring side to do it. She must discharge him to his truck even though she knows that he will not do well. This is type of case that Havens (2000) says will drive nurses away from nursing. Ethical Issues / Stakeholder Views This case presents us with several ethical issues. John was not able to see his physician because of the loss of his insurance even though he had seen this physician regularly over the last ten years. The perspective of the physician is that he cannot see patients in his private practice (business) if they cannot pay the bills. (Malloy, 2009) Like any other business, he must be able to make enough profit to keep his business open and have a salary. The patient must then present to the emergency room where is found to be advanced enough in his problems to then be admitted to the hospital. Discharge from the hospital occurs even though the patient is not ready to be discharged. This happens because the hospital is a business and must make a profit. They cannot do that if they keep self pay patients for long periods of time, knowing that they will not get paid. The case manager who is a nurse must discharge the patient realizing that he cannot care for himself and understanding that he will probably get worse. She is bound by the physician's orders, and the philosophy of the institution in which she works. She, on the other hand is also bound by her own beliefs and philosophy of ethics and those of the code of ethics of her profession. The patient is bound by his own need to keep his truck, which is the only thing he really owns, the county laws and his belief that the healthcare industry will take care of him anyway. The Writers Position John should have been seen by his physician, though there is only ethical and moral reasoning for that decision. The physician took an oath to do no harm but there is not legal pressure for him to see a patient that cannot pay him. The patient should not have been discharged from the hospital though it was a costly case. The case manager should have refused to discharge if she truly felt this was an unsafe discharge as that is a part of her nurse practice act. The patient could be discharged to his truck if that is where he wants to go because it is within his rights to make that decision. If it is not legal for him to live in his truck, the county should encourage him to do otherwise. Discussion In solving these ethical issues, there are many things that we must look at. The Code of Ethics for nursing states that the "nurse provides services with respect for human dignity and the uniqueness of the client, unrestricted by considerations of social or economic status, personal attributes or the nature of health problems." (ANA, 2007). This philosophy is in direct conflict with the "stakeholder capitalism" model that has developed over recent years in health care reform. "Stakeholder capitalism" for healthcare specifically sees healthcare as a business like every other business and the product is the adequate care of the patient (Fry, 2007). This allows the thought that the institution and it's profit is as important as the patient. Stakeholder capitalism supports the hospital and physician in making the decisions they made. This causes conflict in all medical personnel but in particular nurses. This is often the philosophy that today's nurses must work under and so they often the silenced majority (Bryan, 2008). A language of care that emphasizes both relationship and responsibility is noted in Carol Giligan's theory f ethics(Belnap, 2000). The average philosophy of justice in ethics tells us to "aid the needy" while Gilligan tells us to "aid the person". She also feels that partiality is more important than impartiality. Important in the caring code is benevolence or doing no harm. In benevolence lies the idea of maximizing good, not harming anyone, and not interfering with individual's liberty (Hamric, 2007). This philosophy works well with and complements nursing caring theory such as that of Orlando's. Carol Gilligan was the first to take note that ethics was seen a little different based on our gender. (Belknap, 2,000). She noted that women are more interested in care relationships while men are more interested in justice. It is notable that hospitals as business is a justice issue, not a care issue. Gilligan tells us that the female goes through several levels of decision and growth before she at her final ethical self. Realizing that men are also nurses; they do think about ethics in a different way and we may see nursing change as more men enter the profession (Gundstein, 1993). It is also interesting to note that those people that nurses report to in Senior management and those making decisions for the hospital with the exception of the CNO are men, including physicians. Most ethics was developed in the west for over two thousand years without the input of women (Freidman, 2010). Women did not have a voice in ethics until this century. That, of course, means that ethical principles were essentially determined by men. Women ethical views are grounded in ending oppression, subordination, abuse, and exploitation. In Gilligan's levels she talks about self interest, self sacrifice, and post conventional thinking. Each of the levels is complex (Lefton, 2000). How women come to real life decisions is based on self morality for women. In this case, the first discharge was an issue that made the nurse feel very guilty. Everyone told her it was the right thing to do for the institution and that the patient had the right o make his own decisions. All of that was true but when we look at the definition of ethics, for this nurse, it was probably did not feel ethical. However, the caring philosophy as well as the nursing code of ethics tells us that the patient has the right to make his own decisions and live how he chooses. Nodding tells us in "Starting at Home: Caring and Social Policy" (2002), that Gilligan and her principles in stating that children have a natural need for caring which motivates them to help others is correct. As we grow older we have a tendency to forget about spontaneity and natural caring and all things have to have a reason or a place on our calendar. Nurses in particular have this problem as they have a job that encourages their caring but in that job there are so many tasks that caring has to be scheduled. It becomes that much worse as we step up to the management plate to find ourselves to important to the institution to care (Beauchamp, 2007). We tap into what we remember as caring when it was easy for us and when we had the time. Natural caring is the condition of ethical caring. Sociopaths for example, cannot care ethically because they cannot care naturally. Nurses learn to use their natural caring ability to facilitate ethics in their practice (Beauchamp, 2007). We, because of these beliefs, are often conflicted between the needs of the institution and the needs of the patient. To become "important" i.e. manager etc, we must be able to see the institutions side. The nurse case manager in this instance is truly caught in the middle of the ethical and legal battle of what is right and what is wrong for this patient. The nurse case managers of today are often very conflicted. The newer philosophy of casemnagement is definitely founded in finances and not patient care. In the need to be caring individuals, these nurses are consistently trying to be advocates for their patients while at the same time they must be responsible to their jobs which is the finances of the institution (O'Donnell, 2007). These are the kinds of issues causing the type of conflict that the case manager had in discharging John. Her caring nursing perspective created the need to keep him in the hospital longer while the "stakeholder theory' of her position created the need to discharge him. John's physician made a decision not to see him though he was a long time patient. This writer feels that the patient should have been seen. From the nursing perspective, this patient deserves to be seen like anyone else regardless of his ability to pay. John was discharged from the hospital too early which again was a financial decision, not a caring decision and if we are to look at the caring perspective, we would not yet discharge him because we would do no harm and knowing that would extend his stay until he was better. Lastly, John was discharged to his vehicle. This at first, seems to be the "wrong" thing to do but if evaluated using the caring perspective, it was the "right" thing because John has the right to live the way he chooses whether or not we are comfortable with it. Moral Action Plan The action plan for the result of this situation has to be comprehensive, certainly dealing with far more than the result of this one patient. It is clear that this is not the only instance where this has occurred and a moral plan of prevention should occur. Nursing has a strong ethical background which has been shown in our discussion of Gilliam and her caring philosophy, as well as others previously discussed so they must work in an atmosphere that allows that kind of morality and ethics. The government needs to consider how to fill the holes where a patient may lose his insurance and no longer be able to get care. This is particularly true of someone who has been working, has a chronic illness and is in need of healthcare to remain stable. The long term effects of allowing this patient to get more and more ill is a much higher cost to society in general. Possibly this could be determined through an advisory group of nurses. Hospitals must realize that though health care is being deemed a business, no other business is caring for patient's lives. There are moral obligations that are not the same for any other business and nurses cannot work in a situation that requires them to do away with their caring attitudes and take on a financial one. This hospital will need to work closely with its nurses and case managers to determine a policy that would allow a nurse case manager to not discharge an unsafe patient. This is also within the best interests of the hospital in the sense of patient satisfaction scores and relief of possible legal recourse. Finally, for everyone involved in the plan, the patient must continue to have the right to make their own decision. This must be a part of the hospitals philosophy and as hard as it can be sometimes, it must also stay a part of the nurse's philosophy. Conclusion Ethics is difficult for everyone but is especially difficult for nursing. Nurses, like most females learn to care when they are quite young and it becomes part of their being. They are unable to change how they feel about moral and ethical rights to meet the needs of an institution. In today's world of medicine, nurses are often driven from their places of work because they are forced to make ethical decisions that are against their beliefs. Carol Gilligan was able to define ethics in such a way as to meet the nurse's natural need to care. She has helped in stopping the silence that nurses have had in most western institutions for some time. The case of John was a difficult case and there were many who were stakeholders in the case. The conflict is not only a moral one but one of determining the larger question of what healthcare is and where doe it's moral and ethical responsibility lie in regard to patients. Might there be a way in which to allow healthcare personnel to actually do what they do best and take care of patients in the way they feel is moral and ethical while someone else worries about how that gets funded The profession of nursing may continue to find itself without new blood and decreasing numbers of old blood if they do not find a way to solve the issue of caring versus finance. References Bandman, E. Nursing Ethics Through the Life Span. 4th ed. Printice Hall, Inc.: Boston. Belknap, R.A. (2000). One womans life viewed through the interpretive lens of Gilligan's theory. Violence Against Women. 6. 586-605. Beauchamp, T. & Childress, J. (2005). Principles of Biomedical Ethics. 6th ed. Bryon, E, Gastmans, C, Casterle, B. (2008). Decision-making about artificial feeding in end-of- life care: literature review, Journal of Advanced Nursing 63(1). 2-14. DOI:10.1111/j.1365-2648.2008.04646.x Code of Ethics for Nurses with Interpretive Statements: American Nurses Association. 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