Legal Ethical Nursing Situation - Essay Example

Running Head: LEGAL ETHICAL NURSING SITUATION Legal Ethical Nursing Situation [The [The of the LegalEthical Nursing Situation Introduction Nurses working in the field of HIV/AIDS epidemiology are often best placed to understand the anxieties, values, life problems, rights and obligations of sufferers. Yet they have very little voice in this field. Nurses working in the epidemiological process often find themselves in morally problematic situations. Although the employment of nursing personnel in the data collection, record keeping and other disease surveillance aspects of epidemiology is widespread, the value and quality of their work is unrecognized and unrewarded. The dilemmas nurses face in this position when issues such as consent and confidentiality are not properly aired and discussed can be severe. (Scott, 2000) Practice sisters in GP group practices who often do the actual disease notification are not the ones to receive the statutory payment. Senior HIV/AIDS discharge co-coordinators (nurses) and research nurses have been employed with part of their job defined in terms which are normally part of the doctor's role. Needless to say, they are paid less than doctors. There is generally a lack of recognition and concern for the dilemmas nurses are faced with in this field. Although the ethical codes of both the medical and nursing professions are not at odds on these matters, the actual practice is. In fact, the nursing code in particular is quite advanced and very clear, but the conflicts and power struggles which still exist between medicine and nursing make it very difficult for nurses-advocates of the patients-to live by the letter and spirit of their code. Not only does the individual nurse suffer in this situation, but any decent nurse is forced into defending the rights of the patient in opposition to the quality of the data collected. This is not an argument against nurses entering the field of epidemiology, but rather an argument for bringing the rights of the individual patient and the public aims of epidemiology and health policy together. Nurses are often in the best position to identify these problems and should be listened to. (De Selincourt, 2000) Literature Review/ Case Study A young woman, Amanda, is pregnant. She attends the antenatal clinic, where a midwife takes her health history and runs a series of tests, such as blood, urine and blood pressure. She is counseled by the midwife on, among other things, the implications of human immuno-deficiency virus (HIV) and of being tested for it. Although the midwife has no reason to believe that Amanda has been exposed to HIV, she offers her an HIV test. Amanda declines, as there seems to be no need for one. She is also aware of the difficulties in obtaining a mortgage if she has this test. The blood sample taken by the midwife is sent to a laboratory for analysis for hemoglobin content, rubella antibodies, and syphilis. At the same time a small amount of blood from this sample is placed in an unnamed test tube which is then sent to a central laboratory to be tested for HIV. The midwife is completely unaware that this has occurred so cannot inform Amanda. The next time that Amanda visits the antenatal clinic the other blood results are returned to her and, as they are normal, she continues with her pregnancy uneventfully. Unknown to her the anonymous blood sample has been tested and found to be HIV antibody positive and this is recorded at the national surveillance centre, where data on HIV and acquired immuno-deficiency syndrome (AIDS) and other infectious diseases are collected. The information accompanying this sample includes Amanda's age range (i.e. between 35 and 40 years), her gender and the geographical origin of the sample. In this case the epidemiologist will not have information about the means by which HIV was contracted. The data will provide information about the trends of HIV among pregnant women who attend antenatal clinics over a five-year period. Amanda's pregnancy continues normally and she delivers a healthy baby. The baby has a heel prick blood test (Guthrie Test), which is routinely performed on newborns to detect phenylketonuria (PKU) and hypothyroidism. In this case it includes a test for HIV. The PKU and hypothyroidism tests are linked to the baby's identity and are done with Amanda's knowledge, but the HIV test is anonymous and is done without her consent or knowledge. Antibodies to HIV are detected, but it cannot be known whether these are 'maternal' antibodies circulating in the baby's blood-stream temporarily, eventually to disappear, or whether the baby actually has HIV infection. In any case, although this HIV antibody positive result contributes to more epidemiological evidence accumulating about HIV, no benefit has accrued, or can accrue, either to the baby or the mother from the test at this stage. Amanda was not informed about either of the HIV tests and was not given the chance to decline or give her consent. So, appropriate social and health benefits cannot be made available to Amanda, as she has no knowledge yet of her baby's or her own HIV antibody status. The months pass by and Amanda begins to feel unwell. She develops swollen glands and experiences night sweats. On consulting her general practitioner (GP) a blood test is taken and a tentative diagnosis of glandular fever is made. Weeks go by and she returns for her result-negative. She is still ill and after much consideration and discussion her GP offers her an HIV test. The time waiting for the result is fraught with anxiety and the GP is apprehensive too. The test is positive, and so is a test on the baby's blood. Time passes, and soon the various opportunistic infections which Amanda develops puts her in the 'AIDS' category. Her GP informs her of this, although it makes very little difference to the care he gives her as she is treated for every infection according to the current practice. (Chrystie, 2002) However, Amanda is troubled by this new label. Her GP had mentioned on the form that she was not a drug user, had not received infected blood products, and that she had said she had not behaved in a 'high risk manner'. (Kultgen, 2004) Approached through her GP, Amanda gives permission for the interview. The epidemiologist explains to her the purpose of the study. Amanda is interested not only in the reason for the interview but in how the interviewer had come by the information about her and her AIDS status. She is perplexed to learn that her GP, who had respected confidentiality so far, had sent information about her to a central surveillance unit without informing her or asking her permission. She begins to wonder how many other people know of her illness and whether this information is going to benefit her care or indeed be beneficial to any other people living with HIV or AIDS. She feels rather let down by her GP, but agrees to continue with the interview. The interview takes several hours and she is asked very intimate questions about her sexual behavior and history. The interviewer tries to establish whether the contact was only sexual, or whether it was with someone who had behaved in a 'high risk manner' (Curtin, 2003), whether the person was from a country where the heterosexual spread of HIV is common, whether her partner had been bisexual, or whether she had had a sexual partner about whose sexual history she was ignorant. As Amanda's trust in the GP had now broken down he began to act defensively, and Amanda decided to complain to the interviewer's employers. She complained about what she regarded as a breach of confidentiality by the GP, as he had not asked for her consent to pass on the report, and also about the upsetting interview. However, it now seemed that the interviewer had breached his own professional code of conduct, for he was in fact responsible for all the relevant actions carried out by him whether ordered by his superior or not. He was wrong in thinking that his superior would have to carry the can alone. The director of the surveillance centre then gave Amanda an apology for the distress caused her and went on to explain how important and useful the information gained from her would be for the epidemiology of AIDS. Summary There are five themes of moral and legal concern which emerge from this scenario. The themes are: 1 The anonymous HIV antibody test done on Amanda's blood at the antenatal clinic without her consent. 2 The anonymous HIV antibody test done on Amanda's baby without consent. 3 The GP's report on Amanda's AIDS status to the national surveillance centre, without her consent and possibly breaching confidentiality. 4 The circumstances of the epidemiologist's interview. 5 The conduct of a research study (of which the interview was a part) without ethical approval. Possible Changes in Nursing Practice for Resolution of Issue In this case, there are certain personal difficulties which arise for health care professionals themselves. After all, they have a duty, not just to collect information, but to care for the people they are gathering information from. Certainly, collecting information, especially by interview, in these special circumstances, cannot be done by people who have no caring role whatsoever-like census interviewers-who can remain completely detached. Training in bereavement counseling and listening skills is of great value but does not adequately answer the question of how to care for the carer. Unfortunately this is a problem many employers do not wish to hear about. Nurses in particular are often under great strain. The employer has a moral responsibility to provide adequate support to research workers who are involved in highly emotive, and grief-laden situations. On balance, the interview process in the present context, with all its ramifications, creates more problems than it resolves. Although the upset and anxiety may not have been completely prevented, still the conduct of the interview could have been quite different if Amanda had consented to the report instead of just being automatically recorded as an 'AIDS case', and if the research protocol had been properly examined by an ethical committee. Recommendations for Nursing Research For Better Dealing With The Issue Submission of the research study to an ethical committee at the Public Health Laboratory Service may not have entirely obviated the causing of upset to Amanda, but it may have minimized it. This would depend on how good that committee was. An ethics committee, if it approved the interview research at all, might have demanded that it be made sensitive enough to have ensured that the interviewer was better prepared for his delicate task. The absence of official ethical approval for the research study is a prima-facie wrong. The epidemiological surveillance can properly be regarded as research and whether HIV and AIDS can be considered to have the same moral and ethical connotations as other diseases, notifiable or not. There are certain ethical problems which are highlighted by a research nurse working in epidemiology, such as myself, and governed by a strict code of conduct, who has to work with doctors and others who may simply not see the moral aspects. It might be argued that surveillance is not research, that this is generally undertaken without official ethical approval and that in any case epidemics require rapid responses which the approval process would obstruct. We should assume that surveillance of any disease, notifiable or not, requires such approval unless some overriding reason can be provided. If urgency does not permit a scrutiny of each and every study, then perhaps a standard approach could be agreed in which policy decisions are made public. For example, the policy that consent will be obtained, or will not be obtained in such and such circumstances for such and such reasons, or that people will always be informed of surveillance activities, or that confidentiality will be respected by such and such means. (De Selincourt, 2000) Conclusion One might have expected that at least the health care personnel involved would be fully informed. However, in practice this would amount to informing the patients, because the nurses and midwives would have had a professional duty to inform their patients and clients. This would have led to a demand for consent procedures. Alternatively, nurses and midwives might have been pressured to ignore this duty, which would have been unethical and created enormous difficulties. It seems that the foreclosing of consent, and the withholding of information, both from patients or clients and from health care staff, shows a lack of respect for both groups. The very idea that pregnant women represent the 'heterosexual population' is misconceived. The alternative of anonymous screening with consent is proposed, which would also have the epidemiological advantage of allowing matching of data with the current demographic data from an area. This way the patient/client is respected, the chance to give or refuse consent is allowed and, should people refuse; some sensitive non-threatening enquiries could follow into the reasons for refusal, reasons which may themselves be enlightening for educational purposes. Practice nurses should be familiar with the AIDS surveillance form filled in by GPs. In the scenario the GP had a choice of putting down Amanda's name or using a code, and he chose a code. This is an alpha numeric code, which cannot be decoded easily, and thus provides a degree of confidentiality. However, the GP also fills in the form with Amanda's date of birth, address, occupation, sexual preference, route of transmission of HIV, if known, and various clinical details such as when she became HIV antibody or antigen positive, when she developed AIDS and what infections she has which fulfill the case definition of AIDS. Although confidentiality is stressed in medical ethics the legal protection available for health information not related to AIDS is limited. In civil law there is a duty of confidentiality, and a patient could claim damages for economic loss resulting from breach of confidence. However, it is unlikely that claims for mental distress resulting from disclosure of medical information would succeed. (Sanders, 1998) A breach of 'such usual confidences as arise between doctor and patient' should be an offence, but this has not been adopted. References Chrystie, I.L., Palmer, S.J., Kenney, A., Banatvala, J.E., 2002. 'HIV Sero-prevalence among Women Attending Antenatal Clinics, The Lancet, vol. 33 (8 February 2002) p. 364 Curtin, L. and Flaherty, M.J. (Eds), 2003 Nursing Ethics: Theories and Pragmatics, Englewood Cliffs, USA: Prentice-Hall. De Selincourt K., 2000. 'A Breach of Trust' Nursing Times, vol. 88 (11), p. 19. Kultgen, J., 'The Ideological Use of Professional Codes', in J.C. Callahan, 2004. Ethical Issues In Professional Life, New York Business and Professional Ethics Journal, vol. 1 (3), pp. 53-69. Sanders, D. and Dukeminier, J., 1998. 'Medical Advance and Legal Lag', Law Review v. 15, pp. 377-8. Scott, G.E., 2000. Moral Personhood, Albany: State University of New York Press. Read More