Ethical Dilemma in Nursing - Research Paper Example

? Ethical Dilemma in Nursing The nursing profession is guided by ethical principles that ensure that the patient care is performed at acceptable standards. Ethical principles such as non-maleficence, beneficence, autonomy and justice are the basis of the profession, directing the code of conduct of nurses as well as patient care (Brody, 1998). The practice of nursing involves caring and maintaining the well-being of patients as guided by the ethical values. Nurses encounter ethical dilemmas in different medical situations (Davis, 1991). Patients have the autonomy of choice to decide the medical intervention that will be provided and in some situations, the patient’s choice conflicts with the health care provider’s ethical values. Ethical dilemmas are clinical situations where the beneficent care giving interventions or ethical values of health professionals conflict with a patient’s or family member’s wishes (Melia, 1992). Nurses are obligated to respect a patient’s choice and enforce the decision within the law and standards of the profession. Nurses may also have personal values that may conflict with a patient’s choice and it is important in all situations that nurses respect the patient’s choice. Ethical principles exist in the profession so as to guide the conduct of nurses and when faced with ethical dilemmas, the basis for decision making for the health care provider is guided by these values. Table of Contents Abstract 2 Table of Contents 3 1.0Introduction 5 2.0Case Study 5 3.0Ethical Conflict 6 4.0‘Respect of life’ versus client choice’ 7 5.0Ethical principles presented 8 5.1Autonomy 8 5.2Beneficence and Non-maleficence 9 6.0Stakeholders involved and their role 9 6.1The Baby 9 6.2The Parents 10 6.3Nurses 10 6.4Doctors 11 7.0Personal values on the situation 12 8.0Possible options 12 8.1Maintain life support 12 a)Benefit 12 b)Consequences 13 8.2Discontinue life support 13 a)Benefits 13 b)Consequences 14 8.3Guidance from an ethical committee 14 a)Benefits 14 b)Consequences 14 9.0Recommendation 14 10.0Conclusion 15 List of References 17 1.0 Introduction Nursing ethics guide the professional conduct of nurses during patient care. These ethics share several principals with medical ethics and can be distinguished by the emphasis nursing ethics have on human dignity, formation of caring relationships and collaborative care. Principals such as justice, autonomy, non-maleficence and beneficence are core to the nursing profession (Brody, 1998). The ethical principles guide the everyday practice of nurses to ensure good patient care and to practice within the acceptable code of ethics. In the nursing profession, nurses usually encounter medical situations that present ethical conflicts. Nurses actively participate during ethical decision making in clinical situations and these decisions may conflict with a patient’s or the family’s decision making autonomy. This presents an ethical dilemma to the nurse whose practice is guided by ethical principles but having the responsibility of providing decisions that conflict with these principals. 2.0 Case Study Baby Grace is an infant who had a low heart rate at birth with breathing difficulties and also exhibited no movement of her extremities. She was intubated and is supported by a mechanical ventilator. Diagnostic tests revealed that there was a hemorrhage high in her cervical spinal cord, the prognosis being poor. The parents have kept her on the ventilator life support for three months, with the hope that their baby would recover. There is little chance of recovery and Baby Grace’s quality of life is poor. Nurses view the situation as the importance of human life, the baby’s condition stabilized and they are reluctant to remove life support. The parents are unsure of the decision to make. 3.0 Ethical Conflict Nursing is a dynamic as well as a complex profession especially in situations where decisions that have to be made hang in the balance between life and death. Beneficence and non-maleficence codes of conduct indicate that nurses should ‘do good and not harm’ and ‘prevent intentional harm’ during patient care (Brody, 1998). In the efforts of doing this in the process of patient care, there must be respect of other values that surround the same patient –as exemplified in ethical principle of client autonomy- which many times brings conflicts. Weighing the benefits for the patient care, particularly embedded in current technological advancement in prolonging life, the ever-changing societal values and other evolving concerns have continued to put nurses within hard choices. These choices made consequentially have ripple effects on all stakeholders within nurses’ and patient’s values and therapeutic environments. These stakeholders are the nurses, patient, parents/guardians, doctors, ethical committees and others that may be involved. Oftentimes within these ethical conflicts one can’t provide concrete solutions since there is no best solution that is applicable in all situations (CNO, 2000). The above case exhibits typical, although mild, ethical conflict where baby Grace is standing in between parents autonomy of choice and the nurses’ ethical duty to ensure Grace’s well-being by exercising the ethical value for ‘respecting life’. This case further reveals some antagonism between the nursing assessment for the baby’s medical need and parent’s wishes. Studies have shown that hospitalization is a prime stressor for parents and hospitalized child (Brody, 1998). Having been diagnosed with hemorrhage in the cervical spinal cord, Grace’s chances of having future paralysis are but highly possible, which neither the nurse nor the parents would wish for. However the parents see paralysis as grave medical condition that deprives their child a status value of ‘well-being’ and with all the required rights within their definition for life; they are thus unsure of which decisions to take for baby Grace. The baby’s parents are the guardians and they have the responsibility of making decisions for the baby. This is according to the Substitute Decisions Act, 1992. The parents also have the right to consent any medical intervention that may be performed on the baby, according to Health care consent Act, 1996. An ethical dilemma presented in this scenario is ‘Respect of life’ versus client well-being/ quality of life.’ 4.0 ‘Respect of life’ versus client choice’ In assessing the medical position for baby Grace, there is even more risk for unfavorable outcome for Grace especially after showing no signs of recovery after staying in the ventilator for three months with no MRI done on her, which would have otherwise given the chance for some augmentable prognostic information. In addition, since Grace shows no effort to breath, the necessity to be aided by a ventilator to provide pressure, respiration rate and oxygen is inevitable in order to prevent any extreme outcome, like death. Respect of life is one core ethical value in nurses’ profession and it indicates that human life should be protected (Keyserlingk, 1979). All health care professionals are guided by this principal in the effort of preserving human life. In this situation, baby Grace is kept alive by the life support machines and the nurses are guided by the ethical principle to maintain support of this life. The prognosis shows that there is little chance of recovery and the child’s quality of life is poor and will continue to be in this state. The parents of the child continue to maintain the baby’s life even in this situation. The parents are unsure after the three months whether to continue their baby on life support or not. They may choose to decide to take her off the ventilators based on the outcome so far indicating no sign of improvement or chance of recovery. Sometimes the client’s wishes, in this situation the parents being the decision makers of the baby, may conflict with the nurses’ ethical values. The nurses are guided by the principal of ‘respect for life’ and would care for the patient in maintaining this life even in dire situations (CNO, 2000). This may conflict with a client’s decision when they choose to take the baby off life support. Although nurses may disagree with the client’s decision, they have to respect the client’s wishes within the law and standards of practice. 5.0 Ethical principles presented This case primarily touches on two ethical values that are universally and legally endorsed in nursing profession. 5.1 Autonomy Patients have the right to consent or refuse care that is provided by health care providers. The patient with a capacity to make decisions are provided with all the information regarding the care that may be provided to them and from this they are able to make informed decisions regarding the type of care they may want (Hope, 2004). The patient decides what is best for them and these decisions may be influenced by cultural or religious beliefs that the patient has. Health care providers have to respect the decisions made by patients, within law and standards of practice, even in situations where the decisions conflict with the ethical values that the profession adheres to. In the case of baby Grace, the parents are the decision makers, deciding interventions that should be done in regard to their baby’s condition. The parents made the choice of keeping baby Grace on life support for three months with the hope that she would recover, despite the poor prognosis. The parents may decide to take the life support off the baby so as to stop the baby’s suffering and this will conflict with the nurses’ ethical value of respecting life. The nurse is obligated to also respect the parents’ wishes. 5.2 Beneficence and Non-maleficence This relates to doing no harm (beneficence) and prevention of intentional harm (non-maleficence) during patient care (Hope, 2004). In some medical situations, it is difficult in deciding the best action in patient care regarding the two ethical values. In baby Grace’s condition, the quality of life/ wellbeing is poor and also this conflicts with the decision to prolong her life with technology which may not be in the best interest of the patient. The caretaking nurse for baby Grace is bound to operate within the ethical values, however she is also limited in assuring the eventual ‘well-being’ of the baby. The hanging solutions to Grace’s recovery are complexly intertwined between human efforts, technological assistance and the severity of baby’s condition. Therefore assuring the well-being of Grace, which is totally encompassed in her uncertain total recovery, is not possible. Therefore the nurse is in a dilemma of having to assure the parents of Grace’s well-being yet she is required to uphold the values. Weighing of potential benefits and harm to the patient is a strategy that is used to make decisions in difficult situations, with consideration of the parents’ wishes. 6.0 Stakeholders involved and their role The stakeholders that are part of this case situation are the baby (patient), the parents, the nurses and the doctors. All the stakeholders have a role in this situation and which may conflict with the other stakeholders’ responsibilities. 6.1 The Baby The baby is the patient and in this situation and suffers from total paralysis as well as being on life support. The prognosis of the condition is poor, indicating that there is little chance of recovery. The situation requires an intervention on whether to keep her on life support or not and the other stake holders have role in determining how to handle this situation. 6.2 The Parents The parents of the baby have the responsibility of caring for their child and making sound decisions regarding the well-being of the child. The role of the parents is recognized during the child’s illness (Melia, 1992). The decisions made by the parents are made out of parental concern for their child’s wellbeing. The decisions are also affected by the parents’ cultural or religious beliefs, which they use as a guide to make the best medical decisions for their child. The parents’ autonomy of choice may conflict with the ethical values upheld by the medical staff. For example, the choice of taking baby Grace off life support conflicts with the medical ethical value of respecting human life. Although there may exist conflicts, the medical staff is obligated to also respect the wishes of the parents within the bounds of the law and standards of practice. 6.3 Nurses The nursing profession is guided by ethical values and a code of conduct that must be followed strictly during patient care. Nurses have the responsibility of caring for patients and also making decisions for the patient’s well-being (Veatch, 2000). The code of ethics helps to keep a clear perspective and a balanced view of the decisions made. In respect to a patient’s or the family’s right to autonomy, nurses may face ethical conflicts in some clinical situations. In baby Grace’s case, the parents may decide to take off the life support for the baby and this conflicts with the nurses’ ethical values of respect of life. The nurses’ have to respect the client’s wishes, having made an informed decision (Bialk, 2004). Nurses also have their own personal values and beliefs that may conflict with their responsibilities. It is important that when these beliefs hinder the provision of care, the nurse in question is obligated to withdraw from the situation and reassign care to another caregiver. Nurses are also required to respect other healthcare professionals’ and their roles in patient care and work as a team for the well-being of the patient. 6.4 Doctors Doctors practice within medical ethics that mainly indicates that all decisions and actions must serve the best interests and wellbeing of the patient. The responsibility of the doctor is to provide the best medical intervention for the care of the patient (Purtillo, 1993). The patients and the families are informed of the care that is to be provided and they also have the autonomy of deciding whether to receive certain care. Informed consent from patients or family members allows doctors to provide care. A patient’s choice may also conflict with the ethical values that guide the physician but respect of the choice is done within the standards of the practice and the law. Doctors in baby Grace’s situation have the responsibility of maintaining her life and informing the parents of the expected outcome of her condition. The parents have the right to decide whether to continue keeping their baby on life support despite the poor prognosis or take her off the support. The doctor has to act according to the decision provided (Veatch, 2000). One of the ethical values that doctors act by is respect for life and maintaining of life, and if the parents’ choice will be to take the baby from life support, the doctor has to do this in respect to this, despite this action being against the ethical value. All the stakeholders involved have responsibilities and are obligated to enact them. The main aim of the parents, nurses and doctors is to make decisions that are in the best interest of the baby Grace and her well-being, despite having ethical conflicts between the parties. The parents make the decisions for the baby and have the autonomy of choice and thus their decision regarding the baby’s situation is respected by the health care providers. 7.0 Personal values on the situation My personal values that relate to the case are include respect of human life and the right to live. I believe that life is a gift that should be protected, preserved and intentional ending of a life denies an individual the right to live. Respect of as an ethical principle of nurses is an issue presented in this case. From an ethical point of view, respect of the client’s autonomy of choice is important. For example, in this case scenario, if the parents decide to discontinue life support for the baby, my personal values should not prohibit me to perform my responsibilities as a nurse. The decision of the parents may conflict with my personal values but as guided by nurses’ ethical principles, the client’s wish should be respected. 8.0 Possible options The possible courses of action that can be taken in this case are: 8.1 Maintain life support The parents have the choice of maintaining the life support of the baby. They have the autonomy to make the decision and this may be guided by their cultural or religious beliefs (Veatch, 2000). This is despite the poor prognosis indicating no chance of recovery from the condition. Medical technology helps to maintain life of the patient, without which the patient can longer live. The baby’s life can only be maintained by life support technology, which brings about the question of her quality of life if the parents choose to maintain life support. a) Benefit The decision to maintain life support advocates for the principle that life should be protected and preserved. b) Consequences The prognosis indicates that there is little chance of recovery and the baby would stay in a paralytic state for the rest of her life as long as life support is maintained. There is the aspect of quality of life, which is affected by total paralysis and dependence on life support. Quality of life is the well-being of an individual and comprises of all social, emotional as well as physical aspects of life. Baby Grace has little chance of recovery and thus these aspects of life cannot be attained. The patient cannot engage in normal life activities and maintaining of life support does not improve her quality of life. Medical technology sustains the baby’s life and if the parents choose to maintain life support they will incur large medical expenses over time. The parents also will suffer from psychological problems due to the state their child, which can also impact their well-being. 8.2 Discontinue life support The baby can be taken off life support as a directive from the parents. The basis for this decision would be from regard of the quality of life of the baby (McClain, et. al., 2002). The health care providers should respect this decision and act on the wishes of the parents, even though this decision conflicts with their ethical values of respect of human life (Snelling, 2004). a) Benefits The baby’s quality of life cannot be improved by maintaining life support so by discontinuing life support; the baby’s suffering will be alleviated. The parents will also not incur medical expenses that come with medical care of life support. Discontinuing of life support is a difficult and painful decision to make but by doing so it will give the parents a chance to grieve the loss of their baby and also help ease their emotional suffering overtime. b) Consequences The choice to discontinue life support is both a painful and difficult decision that the parents will make. The decision to take off life support will also be against religious beliefs or cultural beliefs that the parents may have against intentional termination of life and also having denied their baby the right of a proper natural death. The parents might also feel that they gave up the hope of positive results from the child’s condition 8.3 Guidance from an ethical committee An ethical committee which concentrates on dealing with end of life issues can be approached to give a direction on the issue. The parents meet with the nurses and relevant medical team who are able to provide all the information regarding the situation, enabling the parents to make an informed decision regarding their baby’s condition a) Benefits The parents will be able to make an informed decision on the action to take, after considering all the options. b) Consequences Depending on the decision made, the parents will have to accept the situation as it is. The parents might also feel that the decision made was not entirely their own choice. 9.0 Recommendation The case presents an ethical dilemma regarding end of life situation. The nurses are guided by the ethical values that direct them in the everyday care of patients and in this case there is a conflict between ethical value of ‘respect of life’ and the end of life situation. These ethical values and code of conduct advocate for caring for the well-being of patients. Decisions that are made during patient care and the code of ethics helps to maintain a balanced perspective on the care of patients. The case presents a difficult situation for both the parents and care specialists. From the analysis of the options for a course of action, the recommendation I would give in this case is guidance from an ethical committee on making the decision. The parents, nurses and the relevant team should meet and discuss baby Grace’s situation so as to give direction on the decision to be made. This will help the parents who have autonomy of choice to decide the way forward in Grace’s situation. After considering all options presented by the committee, the parents make an informed decision on what to do. 10.0 Conclusion The ethical principles that guide the practice of nurses include non-maleficence, beneficence, autonomy and justice. These ethical values are the basis of the profession in patient care and direct the conduct of nurses, ensuring the patient’s wellbeing is a priority in all situations. Ethical dilemmas are situations where the beneficent care giving interventions or ethical values of health professionals conflict with a patient’s or family member’s wishes (Davis, 1991). Ethical values, legal matters, personal beliefs and religious convictions all dictate the conduct of nurses. In the profession, ethical values guide nursing interventions during patient care and although nurses may have personal beliefs regarding different situations during patient care, ethical values form the basis of the decisions they make. Nurses face ethical dilemmas in medical situations concerning patients. Nursing ethics advocate for caring and maintaining the well-being of patients and in some medical situations there is conflict between these values and decisions that may be made by patients or families (Hope, 2004). Some patients or their families express the wishes that are inconsistent with ethical values of the medical practice. For example, in view of medical complications, poor prognosis or suffering and pain of a patient’s condition, patients make decisions that conflict with the life sustaining measures that the medical teams enforce. Decisions such as withdrawal of treatment or life support withdrawal conflict with medical ethics of health care givers. Patients have the autonomy of choice and the medical care providers have to respect these choices and act accordingly within the law and standards of practice. Resolution of the ethical conflicts is based on respecting of patient or family wishes, civil and criminal law and direction from the ethical values. It is important that nurses assess the ethical, legal and administrative ramifications of the decisions they make during patient care so that they can make the right decisions for the patients best interest. Therefore an understanding of these aspects helps to form resolutions in ethical dilemmas. List of References Brody, J. (1998). Virtue, ethics, caring and nursing: Scholarly Inquiry for Nursing Practice: An International Journal, 2 (2), pp. 87-95 Bialk, JL. (2004), Ethical guidelines for assisting patients with end-of-life decision making, Medsurg Nurs, Apr; 13(2):87-90. College of Nurses of Ontario, (2000), Practice Standard: Ethics. Toronto Davis, Anne J. (1991), Ethical dilemmas and nursing practice / Anne J. Davis, Mila A. Aroskar. Norwalk, Conn. Appleton-Century-Crofts; London: Prentice-Hall Hope, R. A. (2004), Medical ethics: a very short introduction / Tony Hope. Oxford: Oxford University Press Keyserlingk, E. (1979), Sanctity of life or quality of life. (Protection of Life Series Study Paper), Ottawa, ON: Law Reform Commission of Canada. McClain, K, & Perkins P. (2002): Terminally ill patients in the emergency department: a practical overview of end-of-life issues. J Emerg Nurs.; 28(6):515-22. Melia, Kath M. (1992), Everyday nursing ethics / Kath M. Melia. Basingstoke, Macmillan,  Purtillo, R. (1993), Ethical dimensions in the health professions. Philadelphia, PA: WB Saunders Snelling, PC. (2004), Consequences count: against absolutism at the end of life. J Adv. Nurs May; 46(4):350-7. Veatch RM. (2000): The basics of bioethics. Upper Saddle River (NJ): Prentice Hall: 2nd Ed Read More