Two Ethics Case Scenarios Guest Author - Julie Reeser, RN

Case One: A young woman with a communicable disease is refusing treatment, even though she self admitted to the hospital. You are her nurse and have been told by the previous shift that she is noncompliant and attention-seeking. How do you approach this situation? What are your personal ethics on noncompliant patients? What are your personal ethics on patients who may be contagious and are requiring extra attention? Professionally, you are obligated to provide the same standard of care to each patient. This is an in-the-moment perspective. If she is going to comply at discharge is not your current concern. Your current focus should be on getting her to trust the staff and the situation enough to accept the treatment being offered. She must have had something critical enough to her comfort level to have brought her to your facility to begin with, start there. The scenario has personal judgment from the previous shift. Try not to let that cloud your professional vision. Be wary of patients who may attempt to split staff based on those judgments. If she continues to refuse treatment, be sure to inform the physician so that he can change his plan of care. Document your efforts and outcomes using professional, objective language. Case Two: An elderly man has been admitted to the unit with a GI bleed. He admits to daily alcohol consumption. He is dirty and gruff. He will need several blood transfusions. You are a faithful blood donor to the American Red Cross. Does this set up a dilemma for you? Have you heard other nurses say that they dont donate blood because of patients like him? Are you able to be empathetic and compassionate with this patient? Professionally, you can bring in the team for this patient once he is no longer in crisis. Finding the teachable moments can make the difference. Is this patient depressed? Many elderly are depressed and have turned to alcoholism. Finding a treatment modality for this patient could change his life. Enlist the help of your social worker. Remember in nursing school when they discussed reminiscing language? This patient could benefit from reminders of past achievements and moments of his personal growth. The chaplain services would be a perfect fit for someone who needs this kind of therapeutic touch. Does this patient have self care deficits? Could this be contributing to his feelings of sadness and anger? Perhaps an occupational therapy consult could help him find alternative ways to accomplish his ADL s. Remind yourself why you donate blood. It is to save lives. Whether you choose to improve those lives through nursing interventions is the ethical challenge.

Ethical Principles The ethical principles provide a foundation for nursing practice. Ethical principles are defined as basis for nurses decisions on consideration of consequences and of universal moral principles when making clinical judgments. The most fundamental of these principles is the respect for persons. The primary and basic ethical principles are the following: Respect for autonomy Nonmaleficence Beneficience Justice The secondary ethical principles that can be incorporated with the primary principles when interpreting ethical issues and making clinical decisions are the following: Veracity Confidentiality Fidelity RESPECT FOR PERSONS According to the American Nurses Association (ANA), the most fundamental principle of professional behavior is the respect for persons. This principle not only applies to the clinical settings but to all lifes situations. This principle emphasizes that all people should treat others as a worthy individual. In nursing practice this principle should be simplified. Thus, respect for persons generally means respecting a clients autonomy. RESPECT FOR AUTONOMY Respecting a clients rights, values and choices is synonymous to respecting a persons autonomy. Informed consent is a method that promotes and BIOMEDICAL PRINCIPLES Autonomy

respects a persons autonomy. For a client to make an autonomous decision and action, he or she must be offered enough information and options to make up his or her mind free of coercion or external and internal influences. In clinical settings, this is promoted by proving informed consent to the client. NONMALEFICENCE Nonmaleficence means duty to do no harm. This is promoted by doing the following nursing interventions: 1. Avoiding deliberate harm, risk of harm that occurs during the performance of nursing actions. 2. Considering the degree of risk permissible. 3. Determining whether the use of technological advances provides benefits that outweigh risks. BENEFICENCE Beneficence is doing or active promotion of good. This is done by: 1. Providing health benefits to the clients. 2. Balancing the benefits and risks of harm. 3. Considering how a client can be best helped. JUSTICE Justice is the promotion of equity or fairness in every situation a nurse encounters. The following nursing implications promote justice: 1. Ensuring fair allocation of resources. (example: appropriate staffing or mix of staff to all clients) 2. Determining the order in which clients should be treated. (example: priority treatments for the clients in pain) SECONDARY PRINCIPLES OF ETHICAL CONDUCT Veracity duty to tell the truth Confidentiality duty to respect privileged information Fidelity duty to keep promise

The principle of autonomy recognizes the rights of individuals to self-determination. This is rooted in society's respect for individuals' ability to make informed decisions about personal matters. Autonomy has become more important as social values have shifted to define medical quality in terms of outcomes that are important to the patient rather than medical professionals. The increasing importance of autonomy can be seen as a social reaction to a "paternalistic" tradition within healthcare.Some have questioned whether the backlash against historically excessive paternalism in favor of patient autonomy has inhibited the proper use of soft paternalism to the [7] detriment of outcomes for some patients. Respect for autonomy is the basis for informed consent and advance directives.

Beneficence The term beneficence refers to actions that promote the well being of others. In the medical context, this means taking actions that serve the best interests of patients. However, uncertainty surrounds the precise definition of which practices do in fact help patients. Non-Maleficence The concept of non-maleficence is embodied by the phrase, "first, do no harm," or the Latin, primum non nocere. Many consider that should be the main or primary consideration (hence primum): that it is more important not to harm your patient, than to do them good. This is partly because enthusiastic practitioners are prone to using treatments that they believe will do good, without first having evaluated them adequately to ensure they do no (or only acceptable levels of) harm. Much harm has been done to patients as a result, as in the saying, "The treatment was a success, but the patient died." It is not only more important to do no harm than to do good; it is also important to know how likely it is that your treatment will harm a patient. So a physician should go further than not prescribing medications they know to be harmful - he or she should not prescribe medications (or otherwise treat the patient) unless s/he knows that the treatment is unlikely to be harmful; or at the very least, that patient understands the risks and benefits, and that the likely benefits outweigh the likely risks. Double effect[ Double effect refers to two types of consequences which may be produced by a single action, and in medical ethics it is usually regarded as the combined effect of beneficence and non-maleficence. A commonly cited example of this phenomenon is the use of morphine or other analgesic in the dying patient.Such use of morphine can have the beneficial effect of easing the pain and suffering of the patient, while simultaneously having the maleficent effect of hastening the death of the patient through suppression of the respiratory system. Conflicts between autonomy and beneficence/non-maleficence Autonomy can come into conflict with beneficence when patients disagree with recommendations that health care professionals believe are in the patient's best interest. When the patient's interests conflict with the patient's welfare, different societies settle the conflict in a wide range of manners. Western medicine generally defers to the wishes of a mentally competent patient to make his own decisions, even in cases where the medical team believes that he is not acting in his own best interests. However, many other societies prioritize beneficence over autonomy. Examples include when a patient does not want a treatment because of, for example, religious or cultural views. In the case of euthanasia, the patient, or relatives of a patient, may want to end the life of the patient. Also, the patient may want an unnecessary treatment, as can be the case in hypochondria or with cosmetic surgery; here, the practitioner may be required to balance the desires of the patient for medically unnecessary potential risks against the patient's informed autonomy in the issue. A doctor may want to prefer autonomy because refusal to please the patient's will would harm the doctor-patient relationship.