Professional Values, Ethics and Law - Essay Example

?PROFESSIONAL VALUES, ETHICS AND LAW Introduction The aim of this essay is to explore the ethical, legal and professional issues pertaining to case study 2. It will consider the scenario of an eighty year old woman with Alzheimer’s disease about to undergo an operation for a hip replacement but withdrew consent while on her way to the operating theatre. Ethics is defined by most dictionaries as “dealing with what is good or bad, right or wrong” (Barker, 2011). In context to the health care profession, ethics refers to the principles that must guide the behaviour of a professional in a particular situation (Barker, 2011). Values comprise of a set of socially accepted codes of conduct and in medical profession, values are the standards of conduct or professional responsibilities that are informally accepted and passed on as traditions (Beauchamp & Childress, 2001). Alongside advances in the science of medicine, attempts have been made by moral theorists to codify the ethical and moral principles involved. These principles provide guiding framework that help avoid dilemmas in conflicting situations. The two pioneer ethical theories include Teleologic theory or Consequentialism/Utilitarianism and Deontologic or formalist theory. The Utilitarianism theory focuses on the end and judges actions on the basis of greatest good for a larger group of individuals. Deontological ethics introduced by John Stuart Mill, and supported by Immanuel Kant was judged actions on the basis of motive underlying it. Irrespective of the results or individual opinion, duty must be accomplished without any choice. Principles and duty guide actions. In this respect American Nurses Association (ANA) Code of ethics for nurses provides that the nurses’ primary commitment is to the patient, his health, rights and safety. Further the nurse is solely responsible for his practice. The ethical principles guiding nurses enable them to take moral positions in specific situations (Ivanov & Blue, 2008). Beauchamp & Childress have grouped these principles into four categories: respect for autonomy, nonmaleficence, beneficence and justice. While there is no conflict on the principles of justice (balancing and counterbalancing benefits, risks and costs) and nonmaleficence (avoiding actions that may lead to harm); the remaining two principles of autonomy and beneficence can be considered in this scenario (Beauchamp & Childress, 2001). Autonomy Autonomy originated as ‘self rule’ or ‘self governance’ from the Greek words autos meaning self and nomos meaning rule. It was later broadened to include individual levels. At both these levels, autonomy is indicative of two essential features; liberty or the freedom from controlling factors, and agency that has the ability for an intentional action (Hope et al., 2008). Actions in adherence with principle of Autonomy are indicated by the following three criteria: an understanding of the purpose of actions, actions are intentional and are not controlled by factors that influence the course of action. Intentionality is easy to categorize as presence or lack of same. The remaining two issues can be graded. Thus an action that is intentional, with a high degree of understanding and a low level of controlling influences can be considered as autonomous. The precise definitions of high and low degree cannot be provided, but the appropriateness of the same needs to be judged subjective to the situation (Barker, 2011). The primary consideration supporting respect for autonomy stems from the philosophy of Immanuel Kant and John Stuart Mill mentioned before. They proposed that every individual has an unconditional worth and has been endowed with the ability to make decisions of his destiny. Ignoring these decisions in conditions which disable him to protest would be a violation. Further such a treatment would mean that the person is being used as a ‘means’ to achieve an end (Ivanov & Blue, 2008). With regard to medical profession; respect for autonomy facilitates right of the competent patient to make decisions relevant to their health and life. It encompasses the professional responsibility of the health care providers to disseminate specific and precise information to their patients, thereby enabling them to make an informed decision pertinent to their health. It is also the duty of the medical professional to ensure an environment where the patient is not influenced in the decision making process by other agents; beneficial or the opposite. Further it also entails that the medical professional should respect the decision of the patient, and should not go against it. Irrespective of whether these decisions are considered beneficial to the patient or not, the medical professional must respect the freedom of the patient to take the decisions pertaining his health; and must uphold the decision (if competent). Individual decisions may be influenced by their cultural and religious beliefs. An adult Jehovah’s Witness may decline a blood transfusion even if the decision proves fatal to his life (McCormick & Min, 2008). An autonomous decision thus implies that an individual has made a decision on his own, without being influenced by anyone else; and the decision making process is characterised by rationalisation and understanding of the situation presented as well as the future implications of the decision made. It has been stressed by Hope and associates (2008) that no competent individual should be barred from making decisions related to his life or health on the pretext that his decision is considered unwise by anyone else. In cases of disputes between medical professionals and the patient, the judicial system alone has the right to comment on it (Hope et al, 2008, p40). Beneficence Considering the aforementioned criteria for respect for autonomy, the consultant’s disregard of the patient’s reluctance contradicts the principle of autonomy. A deeper understanding of the rationale behind this principle can enable a better understanding of the consultant’s reaction. The consultant’s decision can be argued to be motivated by certain facts. The patient had already consented to the operation and was therefore being led for the same. Further, the hip surgery would lead to the improvement of the health and living of the patient. Instead of remaining ‘bed-bound’ the patient has higher probability of being active and attaining independence in performance of her daily chores as a consequence of the hip operation. Thus the consultant’s decision was inspired by the principle of beneficence or deciding what under the circumstances would be best course of action with the patient’s ‘best interests’ in mind. Referring again to the previous example, though the principle of beneficence requires that the health care provider recommends a blood transfusion, he can only attempt to convince the patient and respect his decision for better or worse (McCormick & Min, 2008). If we consider the other extreme, the paternalistic approach where the health care provider follows principle of beneficence as the primary guiding force. Decisions regarding patients’ health and course of treatment are made by the medical professional, independent of the patients’ preferences. Thus the role of the doctor is that of a temporary guardian. While the informative approach may be suitable for patients who are competent to make informed decisions and have specific preferences; the paternalistic model suits patients with mental disorders or dementia (Dickenson et al., 2010). This approach is suitable in situations where a patient is incapable of making decisions on his own, being rendered incompetent as a consequence of physical or mental problems. Further the approach is also apt for situations where an urgent decision is essential, a delay due to decision making process can pose significant risk to patient’s health. Further immediate action can lower the risk and prevent or alleviate harm to the patient. Beauchamp & Childress (2009) stress that there can be no ‘reasonable alternative’ that can justify restriction of autonomy. The medical professional’s approach should be one that conforms to ‘least autonomy restrictive’ after an in-depth consideration of the benefits and risks entailing the approach in specific situation. Paternalism/ Consequentialism/ Other Theories The thin line between beneficence and paternalism is sometimes blurred, as probably happened in this case. Paternalism is the traditional approach used in medicine wherein the doctors were allowed to make decisions on behalf of the patient since they were deemed better equipped to do so. Thus in the paternalistic approach the doctor assumes the role of a parent who is entitled to make decisions on behalf of patients’ that are like children incapable of making rational decisions on their own. Though the approach is correct in assuming that the medical professional has higher probability of making accurate decisions for the well being of the patient on the basis of knowledge imparted by his education and experience, but this information guiding the decision making process is exclusively from biomedical perspective. The major limitation of this approach is that the doctors are unaware of the patients’ personal preferences, his cultural and religious beliefs as well as social and family responsibilities (Hope et al., 2008). Professional Aspects From a professional perspective, the patient was reported to be ‘coherent and lucid’ while consenting to the operation. Later the records of the patient revealed early signs of Alzheimer’s. Individuals with Alzheimer’s exhibit symptoms of mood alterations, confusion, anxiety and depression. They are likely to be upset or scared in settings that are outside their comfort zone (10 signs of Alzheimer’s, 2009). Hence patient’s reports should have lead to concerns and demanded further discussions with the patient and involve carers and family members too prior to proceeding with operation. However, a medical professional is liable to act upon perceptions and experiences as much as on the basis of medical and legal facts. It is therefore most important that the professionals act with integrity and honesty towards their profession; and respect patients’ autonomy as well as needs. Besides proceeding in adherence to laws, he should attempt to follow the ethical principles underlying the profession. But above all he should be able to justify his actions and remain responsible for his actions. Legal Aspects Human rights to health are provided in the United Nations Charter and in the constitution of World Health Organisation (WHO). Patient’s bill of rights includes right to ‘informed consent for treatment’, ‘refuse treatment’ and ‘continuity of care’. The ‘informed consent’ clause is subject to condition that the patient is competent and has the ability to make or stand by the decision. Ability refers to capacity to understand the alternatives, costs and benefits of the procedure (Public Health Law). With older patients consent is not a onetime event but a continuous process. With a continuously working mind capable of understanding and rationalizing; a patient can change his decisions (Department of Health, 2001). Even individuals with dementia need to be treated as individuals capable of making decisions, ‘unless proved otherwise’ (10 signs of Alzheimer’s, 2009). The Mental Health Capacity Act (MCA) 2005 too stresses that the consultant must start with the assumption that patient is competent, and must establish it is otherwise before making decisions on behalf of the patient (Farsides, 2007). When the subject is not competent, consent of family members or care providers is sought (Public Health Law). In absence of family members or care providers, the Mental Capacity Act 2005, sections 35-37 have the provision for an Independent Mental Capacity Advocate who is authorized to represent and support the patient (McHale, 2007). It is the duty of the medical professional to inform the patient of these provisions and encourage the use of these services wherever they feel that patient’s condition renders him incapable of decision making. Patient’s health condition and indecisiveness rendered it essential that the consultant should raise concern regarding her competence rather than declaring “these elderly patients don’t know their own minds”. His attitude was in contradiction to the aforementioned clause in MCA 2005 (section 1) that a patient should not be considered incapable unless proved. The legal provisions provide specific course of action needed to determine incompetence. MCA section 2(3) specifies that if a person is not able decide due to an impairment or disturbance that affects the executing capacity of brain, he can be considered incompetent. The criterion applies to individuals with Alzheimer’s disease (Dimond, 2011). Decisions regarding what is in the best interests are based on section 4 of MCA that specifies that previous decisions of the patient must be considered. The patient had provided consent to the operation when she was ‘lucid’. Another legal aspect of the situation arises in case of non-conforming to the protocol according to the MCA, which renders the consultant liable to a civil suit for ‘trespass’, since consent was obtained through proper channels. Conclusion Health care providers at times in view of the good of the patient take control of their health and life related decisions, thereby violating patient’s right to autonomy. In the current case, beneficence and respect for autonomy became contradictory as a consequence of patient withdrawing consent prior to operation. When professional values, ethics and law collide; decision making become difficult. It is clear that the moral and ethical principles may sometimes be at loggerheads to each other therefore, the health care provider must use the broader picture in the decision making process, “one size fits all” simple does not apply in this profession. The present situation did not demand an urgent operation since the risks were not significant. Further discussion to obtain patient consent was affordable since with adult patients ‘consent’ is an integral part and an essential prerequisite of decision making process (Department of Health, 2001). Yet the consultant chose to forego the option and decided to continue with the surgery thereby restricting the autonomy of the patient. The consultant’s approach can at best be explained on the basis of ‘consequentialist’ theory that comes under the broader concept of utilitarianism theory. The consequentialist theory promotes the course of action that would bring the best possible outcomes in a particular situation, irrespective of the opinions of those concerned (Hope et al., 2008). References 1. 10 signs of Alzheimer's. (2009). Retrieved May 2012, from http://www.alz.org/ alzheimer's disease 10 signs of alzheimer's.asp 2. Barker, P. (2011). Section Preface. In P. Barker, Mental health ethics: the human context (pp. 3-4). NY: Routledge. 3. Beauchamp, T. L., & Childress, J. F. (2001). Principle of biomedical ethics (6th ed.). Oxford: Oxford University Press. 4. Dickenson, D., Huxtable, R., & Parker, M. (2010). The Cambridge medical ethics workbook (2nd ed.). Cambridge: University press. 5. Dimond, B. (2011). Legal Aspects of Nursing. 6th ed. . Harlow: Pearson. 6. Departmetn of Health (2001). Seeking consent: working with older people. London: HMSO. 7. Hope, T., Savulescu, J., & Hendrick, J. (2008). Medical ethics and law: the core curriculum. Edinburgh: Churchill Livingstone Elsevier. 8. Ivanov, L. L., & Blue, C. L. (2008). Public health nursing: leadership policy & practice. NY: Delmar Cengage Learning. 9. McCormick, T. R., & Min, D. (2008). Respect for autonomy: illustrative cases. Retrieved 2012, from Ethics in medicine: University of Washington School of Medicine: http://depts.washington.edu/bioethx/tools/prin1cs.html 10. McHale, J. (2007). The legal perspective. In J. Tingle, & A. Cribb, Nursing law and ethics (p. 119). Oxford: Blackwell. 11. Patients' Bill of Rights. (n.d.). Retrieved May 2012, from Public Health Law: http://www.health.ny.gov/professionals/patients/patient_rights/docs/english.pdf Read More