Ethics: Working with an Impaired Physician - Essay Example

?Running head: ETHICS Ethics: Working with an Impaired Physician Ethics: Working with an Impaired Physician Introduction One of the most important functions of the nurse is the collaboration and coordination of care with the members of the healthcare team, especially the primary healthcare provider, or the physician. As a collaborator and coordinator, the nurse serves as a bridge between the patient and the physician. With this role, the nurse is able to fulfill her primary duties to the patient by simplifying jargons, medical terms, and other aspects of the patient’s care that would have been otherwise difficult to understand for the patient. However, as much as the nurse’s role is to his/her patient, the nurse also has a significant duty to protect and work well with the other members of the health care team. As member of the healthcare team, the nurse is expected to defend and protect those that belong in the same profession she is in, provided that such an individual is in the side of what is right. Indeed, with this camaraderie and sense of kinship, a nurse feels indignation in witnessing an injustice towards a fellow nurse, even though the nurse does not know the said persecuted individual. However, an issue then rises when principles of ethics are compromised for the sake of that camaraderie. For example, nurses are sometimes asked to cover up inefficiencies and mistakes, just to protect another nurse or even another doctor. During these times, the nurse is then faced with a major ethical dilemma, especially in cases where a patient suffered tremendous loss. An example of this ethical problem is when an impaired physician commits a mistake and asks a nurse to overlook the said mistake. The doctor’s impairment can be caused by a lot of reasons, but the most common of which is advanced age, or physical injuries caused by accidents and similar occurrences. In these times, the nurse is then divided between her duty to her patients, and her duty to the other members of the health care team, such as the physician: she could either report the physician or she could remain quiet about a certain incident. If the nurse carries out the former, this may lead to the revocation of the physician’s license, but at least the nurse was honest and she can have some sort of peace in her mind. However, if she performed the latter and remained silent, the patient may never have justice, but at the same time, the grieving family may find peace and closure a lot more difficult to achieve if they found that the doctor had a fault in the death of their loved one. This ethical dilemma bears with it a lot of possible impacts on the practice nurse, the patient, the patient’s family, and even society itself. For the nurse, protecting a fellow health professional would compromise the care received or to be received by the patient. However, if negligence was revealed, unity, trust and coordination within the healthcare team may be compromised (Diaz & Stamp, 2004), which can also put the patient at risk for further harm or damage. The first scenario may also place the community at a great risk for negligence and incompetence in the hands of an impaired doctor. In relation, this paper will then elaborate on this ethical dilemma, as well as appropriate courses of action that the nurse may take in coming up with a decision. This paper will first discuss the ethical principles involved in the case presented above, and a discussion of the role of the advanced practice nurse will follow. Afterwards, a literature review of studies exploring the said topic will be conducted, and ethical decision-making will be performed in order to be able to solve the problem by using the ethical decision making theory. More importantly, this paper will attempt to prove that when a nurse is faced with the need to decide whether to report an impaired physician or not, she should opt most of all to protect the patient and report the physician, since the nurse’s first and foremost duty is to the patient. Ethics Involved in Case The ethical principles most involved in this case include the principles of professional solidarity and respect versus veracity and double effect. In its most basic sense, solidarity refers to the unity and harmony of sympathies, purposes, and interests within the members of a certain group or collection of individuals. It can also refer to the fellowship or mutuality of the interests and responsibilities of people. In the field of healthcare, solidarity involves the unity and “one-ness” of nurses, along with their fellow doctors, pharmacists, and others. It involves the protection and upliftment of the rights and interests of the other members of the healthcare team (Tschudin, 2002). Also, respect involves the idea that every person is assumed to be responsible and free, and, as such, should be treated accordingly. Respect also entails that people treat each other as equals, regardless of race, color, socioeconomic status, or even mental capacity. On the other hand, the principle of veracity involves honesty in its innermost core. Under this principle, the nurse is required to be truthful at all times, especially to patients. Indeed, Butts and Rich (2005) noted that under the concept of veracity, nurses are ethically required to speak the truth, and not intentionally mislead or deceive patients. Moreover, the principle of double effect involves the predicament wherein there are two potions available, but each of these can potentially damage one of the parties concerned. In this principle, the nurse’s actions can constitute a good effect, but it brings with it an unintended negative effect. In the case, solidarity and the nurse’s respect for the physician dictates that in cases where an impaired physician who committed negligence or malpractice, the doctor should be protected from possible repercussions. However, in contrast to this, the principle of veracity requires that the nurse should be honest and admit to the patient what truly happened. In addition, under the principle of double effect, the nurse should aim for the positive effect of a confession, but she must also be prepared for the negative effect of the act, which could be the ostracism from the other members of the healthcare team. Double effect can also be seen in the option wherein if the nurse chooses to be quite, a negative effect could be pointed in the risk that the impaired doctor presents to the society, especially to his/her future patients. With these, it is comforting to know that the advanced practice nurse has a lot of roles in resolving an issue. These roles will be discussed in the next section of this paper. Role of Advanced Practice Nurse One of the most major roles of the nurse in this ethical case is a colleague and coordinator. As a member of the healthcare profession, the nurse has the responsibility to uphold the standards of healthcare, not only within herself, but also among others. Moreover, as a coordinator, the nurse is responsible for guaranteeing that the healthcare team should always be in harmony and unity – two things that will be disturbed once the nurse decides to speak out and report an impaired physician. What is more, if the nurse does decide to report the doctor, she stands to lose the trust not only of the doctor she reported, but also the trust and respect of other doctors and nurses who would feel betrayed. However, despite these problems and challenges, two of the most important roles of the nurse involve being a client advocate and a change agent. As a client advocate, the nurse should speak for the patient who cannot speak for himself or herself, especially in this case wherein the client or client’s family cannot complain since in the first place, they does not know the real situation involving the impaired doctor. As an advocate, the nurse should be the one responsible in speaking up for the patient regarding the said issue. In addition, as a change agent, the nurse must initiate changes within the health care organization, especially in cases where an ineffective system is in place. In the case study, a system of silence and condonement could be in place, protecting incompetent doctors from a just punishment and thereby endangering the other patients. Also, reporting a physician can be considered as rather daunting since a common misconception is the idea that doctors are above nurses, and so reporting a doctor to other officials may seem a rather too self-important or even insubordination. Thus, as a change agent, the nurse should be willing to stand by the decision to report the physician, and he/she should also be strong enough to outlast the opposition she would receive from people and other members of the health care team (Daniels, 2004). In order to better understand these roles as well as to determine the nurse’s options, literature review involving the case under study will be presented in the next chapter of the paper. Literature Review Different sources and studies explored the ethical dilemma of working with an impaired physician. For purposes of consistency and clarity, the term impaired physician will be used to refer to any medical practitioner who is incapable of fulfilling his/her personal and professional responsibilities due to reasons including, but not limited to, drug dependence, alcohol addiction, and psychiatric illness (American Medical Association (AMA), 2003). According to this same author, the AMA released a policy (H-275.952) requiring all doctors and similar healthcare professionals to report all unethical, incompetent, and impaired colleagues. Several markers exist to indicate to the nurse that the doctor is beginning to “slip” and that reporting the said doctor is already needed. Some of these signs include the increase or presence of complaints from patients and family regarding the doctor’s bedside manners, poor communication techniques, and his/her quality of care. Another danger sign also includes the doctor’s decrease in his/her concern for the wellbeing of the patient, as well as the increase in the number of “personal problems” that cannot really be explained, all of which were confabulated to cover his/her mistakes and discrepancies in patient care. Also, another sign that the doctor is impaired is the fact that the physician appears deprived of sleep, and his/her emotions are alarmingly unstable. Finally, some other indicators for an impaired physician includes the presence of professional errors (nonresponsive to calls, blight judgment in the clinical setting, incorrect prescriptions, and others), and the deterioration of the person’s care for his/her personal hygiene. In relation, Winter and Birnberg (2002) studied the experience of working with an impaired physician. In this study, the authors analyzed the personal experience of doctors impaired due to either affective disorder, cognitive impairments, and chemical dependency. Winter and Bimberg (2002) looked into eight impaired physicians: one had an affective disorder, two were impaired due to cognitive deficits, and the remaining majority was impaired due to dependence on addictive substances. After collating the experiences of these doctors, the authors then developed a system by which to assess, detect, and treat the impairment. The authors found that among the causes of impairment, the easiest to solve was the one caused by substance dependence, since it only needed appropriate training. However, perhaps the most important finding of the study is the fact that all these doctors would not have gotten helped if not one reported them for necessary referral and actions. Therefore, this tells nurses and health professionals that reporting impaired physicians may not necessarily harm them, but can actually help these doctors to recover and improve. Wilson (2000) agrees with this finding, wherein she stated that in her practice as a trainer and rehabilitation agent, one of the most single determining factor in getting impaired physicians to get help is the report of a concerned colleague, friend, coworker, or family member. Wilson (2000) also acknowledged that reporting a doctor to institutions offering training and rehabilitation is not necessarily harming the said doctor, since most institutions offering help keep the doctors’ identities anonymous. Reporting impaired physicians to concerned bodies and institutions would only take place in cases where a patient refuses to follow the rules and continues to practice, thereby providing a threat to the community. In addition, Malpani and Malpani (2005) also agreed with these earlier authors, even stating that since doctors believe themselves to be above the rest, they tend to be arrogant and unable to acknowledge the fact that they have problems. They also added that since the bond between health professionals is sometimes so strong, people tend to “protect” the impaired doctor from being discovered, believing that they were helping that doctor when they are actually doing the exact opposite. Also, these authors discussed that most people are afraid of becoming whistleblowers because they are afraid of the consequences. Due to these reasons, Malpani and Malpani (2005) emphasized that nurses and other colleagues need to act and help doctors by reporting them to people who can help them, rather than enabling them. Furthermore, DesRoches, et al., (2010) took the topic under study one step higher by looking into the different reasons why most physicians and colleagues do not report co-workers who were deemed as impaired physicians. According to their study, the top reasons why healthcare providers did not report their impaired colleagues were: a) fear of ostracism and retribution, b) certainty that reporting the impaired doctor will be futile, and c) belief that there is somebody else already taking care of the impaired colleague’s problem. Thus, healthcare professionals, especially nurses that these reasons or excuses are not always real, so they need to overcome these in order to be able to help the impaired physician. Ethical Decision Making Theory The ethical decision making theory or model posits that in order to be able to decide which necessary ethical decision to make, the nurse may follow certain steps: determining the problem or issue, enumerating the ethical issues or problems involved in the case, listing possible alternatives, creating a plan of action, implementing the developed plan, and then evaluating the interventions (Bohinc & Gradisar, 2003). Using this model, this paper was able to identify the ethical problem of solidarity and respect versus veracity and double effect. Since most nurses tend to remain silent rather than report the doctor to hospital authorities, an alternative action that the nurse could take would be actually reporting the physician not to superiors, but to institutions that can help them, especially since these institutions can really assess by themselves whether the physician is indeed impaired or not. In cases where there has already been damage (i.e. patient death or injury), then the nurse still has to report the doctor since most courts would hand down a sentence of rehabilitation anyway. Also, the doctor need not look to a long time in jail since the cause of the impairment can actually serve as a mitigating factor for the case. However, this plan of action cannot really be implemented since the case at hand is rather hypothetical and there is no space possible for an actual implementation. However, even though the interventions cannot be implemented, it can be seen based on the literatures presented earlier that reporting impaired physicians and getting them appropriate help would be very successful in answering the ethical dilemma. Conclusion Indeed, collaboration and coordination of are important functions of the nurse, as well as the maintenance of harmony within the health care team. However, when such a role becomes a burden especially in the cases of impaired physicians, ethical issues arise. Nevertheless, this paper has proven that when a nurse is faced with the need to decide whether to report an impaired physician or not, she should opt most of all to protect the patient and report the physician, since the nurse’s first and foremost duty is to the patient. References American Medical Association (AMA). (2003). Impaired Professionals. New York: Author. Bohinc, M., & Gradisar, M. (2003). Decision-Making Model for Nursing. Journal of Nursing Administration, 33(12), 627-629. Butts, J. B., & Rich, K. (2005). Nursing ethics: across the curriculum and into practice. Sudbury: Jones and Bartlett. Daniels, R. (2004). Nursing fundamentals: caring & clinical decision making. Clifton Park, NY: Delmar Learning. DesRoches, C. M., Rao, S. R., Fromson, J. A., Birnbaum, R. J., Iezzoni, L., Vogeli, C., et al. (2010). Physicians' Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Colleagues. Journal of the American Medical Association, 304(2), 187-193. Diaz, J. A., & Stamp, M. J. (2004). Primer on Medical Professionalism. Journal of the American Pediatric Association, 94(2), 206-209. (2005). The impaired physician – healing the wounded doctor. In A. Malpani, & A. Malpani, Successful medical practice: winning strategies for doctors (pp. 272-285). New Delhi: UBS Publishers' Distributors. Tschudin, V. (2002). Ethics in nursing: the caring relationship. New York: Butterworth-Heinemann. Wilson, J. F. (2000). Helping Impaired Physicians Get Back into Practice. ACP (American College of Physicians) Observer. Winter, R. O., & Birnberg, B. (2002). Working With Impaired Residents: Trials, Tribulations, and Successes. Family Medicine, 34(3), 190-196. Read More