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The case study of the well-intentioned nurse presents some ethical issues. The nurse has a responsibility to act ethically in her interactions with the patient. Well-intentioned efforts of protection can be paternalistic and unethical even when they do not cause harm. Informed consent is based on the idea that an individual should be fully informed and understand both the risks and benefits inherent in their choice of treatment. This paper addresses the morality of withholding certain information from a patient. In spite of the good intentions that withholding of information may have it is a breach of nursing ethics. Additionally an individual who is uninformed my may make a choice that is not reflective of his or her true wishes.
Informed consent of the patient serves as the ultimate protection from the hazards of treatment. Hendricks (2000, pp29) points out that the basic premise of informed consent is that the patient has the right to determine what should be done to their body. Barkes (2003, pp23-28) supports this with the argument that the patient ought to have full information on prognosis, complications, discomforts, costs, inconveniences, expectations, risks and any sequelae that their condition and treatment may have. The point of giving the patient this information is so that the patient can make a rational decision.
Consent has several components, disclosure, voluntariness and capacity. Disclosure has to do with providing relevant information to the patient in a way that they can comprehend (Etchell and Sharpe, 1996, pp 177). Capacity refers to a patient’s ability to comprehend the information given to them and to appreciate the consequences of the decision they make regarding their own treatment (Etchell and Sharpe, 1996, pp178). Consent also applies to the refusal of treatment because patients have the right to refuse as well as to accept treatment. The patient’s right to come to a decision without being coerced, forced or manipulated is found in the component of voluntariness.
In the case study of the well intentioned nurse, the nurse has failed to fully inform Marie of the actual nature of her treatment. She does not point out that the injection has to be administered slowly because of how painful it is. Additionally, the nurse uses false information to explain why Marie should get the injection; she states that the doctor may cease treatment, which may not be necessarily true because refusal of an injection does not mean that the doctor should stop all treatment. In this case, the nurse is trying to manipulate the patient into agreeing to get the intravenous injection.
The value of informed consent is grounded on the ethical principle of autonomy and also a respect for persons. This ethical principle recognizes the right of the individual to self-determination (Etchell and Sharpe, 1996, pp177-178). The right is in line with society’s respect for and individual to decide on their own personal matters. The principle of autonomy has increased in importance as values within society have moved to defining medical quality in terms of outcomes which are important to patients rather than healthcare professionals (Rumbold, 1999, pp23; McLean et al, 2003, pp212). It could be argued that the rising importance of autonomy is largely part of a reaction by society to the paternalistic attitudes and practices characteristic of healthcare in the past years. Respect for persons makes it necessary for health professionals to carry out interventions on unwilling patients. Informed consent is also a legal requirement and failure to obtain it may constitute battery whereas treating a patient of the basis of inadequate or incomplete informed consent is regarded by the law as negligence (Etchell and Sharpe, 1996, pp179). The action of the nurse of not telling Marie about the painful nature of the intravenous injection, the nurse has acted in a paternalistic manner and therefore has denied Marie the opportunity to express her autonomy. The patient, Marie has thus become a passive recipient of care as opposed to being an active participant in her own care.
It may be argued that the nurse’s intentions are good as she is trying to ensure that the patient’s stay in hospital is as short as possible. The principle of beneficence may be cited in support of the nurse’s actions and failure to give full information. With this principle in mind, the nurse’s actions may be justified with the fact that healing is the main and sole purpose of medicine. By the nurse giving the medication regardless of the pain that the patient will go through, the nurse will have contributed to the healing process and thus improved the patient’s outcome. Beneficence refers to those actions which promote the well-being of other people (Yeo and Moorhouse, 1996, pp53). In a healthcare context this means taking actions which will serve the best interests of the patients. However, there is uncertainty in the definition of which practices actually help patients. In the case above, perhaps not giving the injection will cause the patient to stay longer in hospital but in regard to the patient’s interests, the patient will have avoided a painful procedure. Additionally, there has been no reported attempt at finding an alternative medication that would maybe cause the patient less pain. Thus in this case it seems that the medical outcome was the greater priority for this nurse.
With reference to the principle of non-maleficence, the healthcare provider has the responsibility of ensuring that they do not prescribe medications they know to be harmful or at the very least the patient should be aware of the benefits and risks that are associated with the treatment and these benefits should outweigh the risks. Donelly (2000, pp 119) defines non-maleficence as a concept that is embodied by the phrase,’ first, do no harm’. This is considered by many people as what should be the primary consideration in healthcare. An enthusiastic practitioner may use treatments that is believed will do good without an evaluation of whether the treatments actually do no harm or have an acceptable level of harm. In Marie’s case, the treatment has not been associated with any other harmful effects other than pain. However in the patient has not been fully informed of just how much pain she will be in. While there is the element of risk and pain in all injections, this particular treatment has more pain than would be expected. The patient too is also particularly afraid of injections, thus giving the injection without fully and truly informing her of what to expect would result in doing harm rather than good. The principle of non-maleficence is not absolute (Donelly, 2000). In some circumstances such as this one, the principles of maleficence and beneficence may be balanced against each other so in order to guide ethical action. For instance in a desperate situation where failure to give treatment will be grave, then the risk of not treating also has the likelihood of doing harm. In this case, there is no element of grave danger shown by failure to give the injection. The only negative outcome perhaps would be longer stay in the hospital and the patient missing her sister’s wedding.
The case study above could also be considered in the light of double effect.
Rumbold (1999, pp24) argues that respect for autonomy is a significant part for the rationale of any health work. Respecting the autonomy of a patient means allowing the patient to decide. For the patient to be make autonomous decisions they need to possess the necessary knowledge to do so. This gives the health professional the duty of ensuring that the patient has all the information they need to make a well reasoned choice. The nurse has a role of providing holistic care to the patient, when the patient’s autonomy is not considered the care that is given fails to be holistic.
The principles of non-maleficence and beneficence are in line with nursing philosophy but the paternalism that is often associated with the two principles is incompatible with nursing philosophy (Rumbold, 1999, pp24; Yeo and Mooorhouse, 1996, pp54). Bellack and O’Neil (2000, pp14) argue that the underpinning philosophy in nursing process and many nursing models is the relationship between patient and nurse is one of partnership. The nurse together with the patient identifies the plans and needs of care for the patient. The nurse encourages the patient as fully as possible in the planning, implementation and evaluation of care. This kind of involvement ensures that the patient’s autonomy is maintained while at the same time the principles of beneficence and non-maleficence are observed.
Consent could be implied or explicit (Etchell and Sharpe, 1996, pp179). Explicit consent is usually given in writing or orally. Implied consent is when the patient shows a willingness to undergo a treatment or procedure by his behavior. Consent given for venipuncture is more implied than explicit; it is implied by the patient’s action of rolling up their sleeve and presenting their arm. In the case study, the consent required is also implied. In spite of this it does not mean that the consent process should not be adhered to and the principles underpinning should not be observed.
It is important to obtain valid consent before carrying out a procedure on a patient. In addition to being necessary as ethical practice in nursing, it is an important component of an effective nurse-patient relationship. Research done by Sulls and Wan (1989, pp,372-379) indicates that providing information on what the patient will feel, what will be done to them in the course of procedures and stressful events helps to reduce negative feelings and distress. Additionally, communication and giving full information has also been shown to increase compliance with treatment and satisfaction amongst patients (Hall et al, 1988, pp657-658).
Ethics by definition attempts to find a balance between the ethical perspective and the medical perspective. In considering autonomy as a parameter for health care, both the ethical and the health care perspective can benefit from the references implied to health. Autonomy can be described as an indicator of personal well-being and the professional’s well-being. The general aim of health care is to do good and have them benefit from it.
Nurses have often been referred to as the advocate of the patient. An advocate has a role of safeguarding clients’ rights against violation and abuse (Rumbold, 1999, pp23-24). Starting from the premise that the patient has rights, then the nurse in the process of providing health care has the responsibility of ensuring that the patient’s rights are met. When the nurse fails to do this, she has failed in her moral obligation to the client. The role of the nurse as the patient’s advocate sometimes means that the nurse may be put in a situation where she will have to defend the autonomous decision of the patient even when the nurse does not agree with such a decision or the decision brings conflict with the doctor. Thus in Marie’s case, the nurse should have given the patient all the information concerning the intravenous injection of procedure so that the patient can make an autonomous decision.