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Ethical Dilemmas in Nursing Practice
Introduction
Nurses constantly face ethical dilemmas in the course of their duties, for they advocate for patients interest in spite of the imposing interests from doctors, relatives, and physicians. Usually, ethical dilemmas occur in nursing when ethical principles appear to contradict each other in that obeying one ethical principle will result into transgression of another ethical principle. According to Nasae, Suttharangsee, Ray, and Lynn (2008), ethical dilemmas in nursing emanate from contradiction of ethical principles such as beneficence and autonomy (p.471). Situations that cause ethical dilemmas are extraordinarily complex, and taxing to the mind because; either course of the decision seems immoral. The option that only remains in the instances of ethical dilemma is to consider other ethical factors while at the same time overlooking others. Resolution of ethical dilemmas requires a rigorous process of decision-making, which enables nurses to address ethical dilemmas for exclusive interests of patients, since they are patients advocates. Proper resolution of ethical dilemmas requires consideration of an ethical nature of actions and their consequences. To explore the resolution of ethical dilemmas, this essay examines an ethical dilemma and explains how bioethical model of decision-making is applicable in its resolution.
The Ethical Dilemma
Given that nurses are advocates of patients, they must always ensure that decisions and actions that they make should be in tandem with ethical principles that guard the interest of patients and protect them against any harm. However, ethical dilemmas do arise that compels nurses to either act in beneficence and nonmaleficence or respecting autonomy of patients and act in veracity. Thus, since ethical dilemmas emanate from application of contradicting ethical principles in a certain scenario, a dilemma that involves a contradiction of varied ethical principles is appropriate to illustrate the complexity of the dilemma and its resolution. According to College and Association of Registered Nurses of Alberta (2005), as advocates of patients, nurses should provide relevant information concerning diagnosis, treatment, and management of condition in accordance with ethical principles (p.7). Thus, rationale for choosing the dilemma is that it entails treatment of patient and disclosure of appropriate information regarding diagnosis and prognosis of a disease.
As an example of ethical dilemma, a doctor admits a fifty-year-old woman after diagnosing that she has gastric carcinoma. The woman has been complaining of indigestion, weight loss and vomiting in which lead doctor to conduct an investigation to determine the cause of her condition. By use of gastroscopy and barium x-ray, diagnosis indicates that the woman is suffering from gastric carcinoma that threatens her life if the doctor does not perform appropriate medical intervention. As appropriate medical intervention, the doctor recommends that the woman must undergo a palliative operation to alleviate pain and stenosis. Since the woman is so distressed and has fears about cancer, the doctor decides that no one should disclose information regarding prognosis of gastric carcinoma for six months and confides with her husband that he should not disclose any information to his wife. However, during the course of treatment, the woman confronts the nurse who is on duty and inquires for the truth since she feels that the doctor and her husband are hiding some vital information from her. Thus, the nurse is in a dilemma of whether to disclose information regarding diagnosis and prognosis of her condition or keep the information confidential and save the patient from experiencing a vast deal of trauma and stress.
The nurse is in a dilemma because, she can either act in accordance with ethical principle of respecting patients autonomy by giving informed consent regarding form of treatment that she is undergoing, or act according to ethical principles of beneficence and nonmaleficence. In the first option, the nurse has the ethical responsibility of ensuring that patients receive informed consent concerning the nature of their condition and treatment methods that doctors employ so that they can make informed choice regarding form of treatment that they prefer. In the case scenario, the doctor and her husband decide to compel the nurse not to disclose critical information of diagnosis, treatment and prognosis of gastric carcinoma because the woman is so distressed and cannot withstand reality of her condition. Hence, the nurse cannot act in respect to patients autonomy because the doctor and the husband restrict her from obeying ethical principle of informed consent. In the second option, the nurse has the ethical responsibility of ensuring that decisions and actions have a basis on ethical principles of beneficence and nonmaleficence. Ethical principle of beneficence ensures that decisions and actions of nurses do promote lives of patients, while nonmaleficence guards nurses from causing deliberate harm to patients. Hence, the nurse is in a dilemma of whether to respect the patients autonomy or act in accordance with ethical principles of beneficence and nonmaleficence.
Aspects of the Dilemma
By denying the woman the information regarding diagnosis, treatment, and prognosis of gastric carcinoma, the nurse positively acts according to ethical principles of beneficence and nonmaleficence. The ethical principle of beneficence requires nurses to make decisions and perform actions that promote health status of patients. The doctor examines the condition of the woman and notes that disclosure of information regarding diagnosis, treatment, and prognosis for a period of six months will aggravate the condition of the women, hence confides with her husband not to reveal any information. According to Wilson-Barnett (1986), although the nurse needs to provide informed consent to the patient, the nurse examines that the woman has immense fears of cancer and notes that disclosure may elicit severe distress and worsen her health condition (p.126). Hence, the nurse cannot be in a position to grant the woman informed consent concerning diagnosis, treatment, and prognosis of gastric carcinoma. Moreover, the nurse acts according to the principle of nonmaleficence by protecting the woman from severe stress. Ethical principle of nonmaleficence prevents nurses from inflicting unnecessary harm on patients. In the case scenario, disclosure of information to the woman may cause severe distress that can aggravate her condition. Thus, the nurse weighs harm versus benefits of disclosure and decides not to disclose information regarding diagnosis, treatment, and prognosis.
The negative aspect of the dilemma is that, the nurse actions are against ethical principles of autonomy and veracity. Ethical principle of autonomy demands that, nurses should provide relevant information to patients concerning diagnosis and available options of treatment, so that they can make informed decisions regarding treatment. Patients have the autonomy to make decisions according to their own interests; thus, ethical principle of autonomy requires nurses to respect patients decisions. In nursing, patients interests should take precedence over the interests of relatives, nurses, or doctors. Hence, nurses need to protect patients from compelling interests of relatives and doctors. However, in the case scenario, the nurse violates ethical principle of autonomy by denying the woman critical information regarding diagnosis, treatment and prognosis of gastric carcinoma, a condition that the doctor diagnoses in her. Nasae, Suttharangsee, Ray, and Lynn (2008) explain that, to offer quality care to the patients, nurses usually avoid conflicts, for they have noble duty of promoting nursing profession by collaborating with others (p.477). The nurse violates ethical principle of autonomy because she does not want to conflict with the doctor and the husband. Moreover, the nurse violates ethical principle of veracity, which compels nurses to tell the truth to the patients. Although the woman has a right to obtain true information, the nurse denies her instead. Hence, negative aspects of the dilemma are a violation of ethical principles of autonomy and veracity.
The ethical dilemma is an extremely complex because it involves stakeholders such as doctors, the husband, the nurse, and the woman. Realizing that health condition of the woman is deteriorating due to stress and phobia associated with cancer, the doctor decides to conceal information pertaining to diagnosis, treatment, and prognosis of gastric carcinoma. Concealing of medical information is essential because its disclosure will cause immense distress that can aggravate the condition of the woman. The husband as one of the stakeholders confides with the doctor not to disclose pertinent information to the woman. Since the husband is a close person to the woman, the doctor should discuss her medical conditions with him, and plan appropriate strategy of treatment and prognosis of gastric carcinoma that makes her sick. Since the nurse is an advocate of patients and conducts treatment and prognosis of the woman for a period of six months, she is a critical stakeholder who can participate in decision-making and implementation. Additionally, the woman is also another stakeholder because she deserves to know her medical condition in terms of diagnosis, treatment, and prognosis. Hence, appropriate resolution of the ethical dilemma requires consideration of all stakeholders in the decision-making process.
Ethical Decision-Making Model
Bioethics entails study and formulation of nursing ethics that are applicable in healthcare. Bioethical decision-making model is a nursing model, which helps nurses to make appropriate decisions when faced with complex dilemmas that require rigorous process of decision-making to resolve them. According to Husted and Husted (2008), for nurses to employ bioethical model of decision-making, they must understand the nature and interests of stakeholders who participate in decision-making and reaching agreements (p.5). Hence, according to bioethical decision-making model, nurses should strive to understand the patients desires, way of reasoning, nature of life, purpose of living and resilience amidst challenges. Understanding of patients is imperative because, it enables nurses to formulate and apply appropriate ethical principles whenever they face ethical dilemmas, which are exceedingly complex for a simple resolution to suffice. The model holds that resolution of ethical dilemmas is a matter of experience because ethical issues have no specified solution. Even though ethical dilemmas may appear similar, the model can differentiate the various circumstances that surround the occurrence of a given dilemma, thus providing a unique way of resolving it. Hence, the model provides nurses with a wide range of tools that are critical in resolution of complex dilemmas according to their unique occurrence among patients and circumstances.
Bioethical decision-making model arose from bioethics in 1970s when health care transformed from mechanistic approach, which involves treatment of diseases, to the holistic approach that entails treatment patients. Due to the advancement of knowledge and technology, medical professionals began to recognize that patients have inherent interests that require protection through application of ethical principles and theories. In 1985, Joyce Thompson and Henry Thompson developed bioethical decision-making model based on ethical principles and reasoning, which have ten-steps that guide nurses in resolving ethical dilemmas that are extremely complex. According to McGonigle and Mastrian (2011), bioethical decision-making model emanated from fundamental basis of understanding of human nature, importance of health care system in upholding human dignity and cultural dynamics of society (p.71). Thus, bioethics focus on the importance of individuals attributes as the basis of ethics. In its development, the model has incorporated various individual attributes into ethical process of decisions making since patients play a significant role in determining the nature of decisions in the process of resolving complex ethical dilemmas. Bioethics, as a health care discipline, empowers nurses to understand varied dilemmas in health care and enable them to guide patients in making appropriate decisions regarding their medical condition. Currently, the model is effective in resolution of complex dilemmas that involve stakeholders such as patients, nurses, relatives, and doctors.
Bioethical decision-making model originates from bioethics, which is a discipline in health care that involves the study and formulation of ethics that guide healthcare professionals in their duties. Given that ethical theories can satisfactorily resolve ethical dilemmas in accordance with ethical principle, bioethics provides a means through which nurses can learn different attributes of patients and make unique ethical decisions that suit their needs. As a discipline in 1970s, bioethics mainly involved formulation of ethical principles and analysis of various dilemmas that nurses do encounter in the course of their duties. According to Husted and Husted (2008), as ethics evolved, bioethics began focusing on motivation of human actions and attaching ethical values of nursing practices and human conditions (p.9). Then, bioethics attempted to define human actions in terms of right or wrong, but they became complex with time due to the advancement in technology and application of ethical principles in various circumstances. As knowledge and technology expanded in health care, medical professionals came to realize that ethics ought to have practical aspect in their application. Thus, bioethics focused on formulating ethics that enhance patients, doctors, nurses, and families to make appropriate decisions in resolution of ethical dilemmas.
Bioethical decision-making model is an effective model of decision-making in nursing because; it guides and aids nurses in resolution of complex ethical dilemmas that require rigorous process of resolution. Currently, the model is particularly significant because it provides for participation of all stakeholders in decision-making. The model recognizes that every stakeholder has indispensable responsibility in the decision-making process, and thus requires consideration of numerous factors that surround ethical dilemmas. Monagle and Thomasma (2004) argue that, stakeholders involved in decision-making must be in a position to collaborate with doctors, nurses, family members, health care system, and the entire community for effective implementation of bioethical decision (p.567). Thus, the model is currently applicable in health care because when nurses and doctors encounter ethical dilemmas, they consult widely to arrive at appropriate decision that befits all stakeholders. Gilliland (2010) argues that, bioethical decision-making model provides a systemic approach of resolving ethical dilemmas that are extraordinarily complex to define them in terms of right or wrong (p.18). Hence, the model is applicable in resolving complex ethical dilemmas, which involve various stakeholders that nurses interact with in their profession.
Application of the Model in Resolution of Dilemma
Bioethical decision-making model is an effective model of resolving complex ethical dilemmas because it has ten-steps that guide and aid nurses in the decision-making process. The first step of the model requires a nurse to review a situation under which an ethical dilemma occurred. In review, a nurse should be in a position to evaluate and identify health problems that a patient is facing, ethical components, and stakeholders involved. In the case scenario, fifty-year-old woman is suffering from gastric carcinoma according to diagnosis of the doctor. Since the woman has extensive fears regarding cancer and is already in trauma, the doctor decides that no one should disclose information of diagnosis, treatment, and prognosis of six months to save her from undue stress. The decision of the doctor puts the nurse in a dilemma as it creates contradiction in ethical principles of autonomy versus beneficence and nonmaleficence. The second step of the model entails gathering enough information regarding ethical dilemma. In this step, the nurse needs to find out why the doctor recommends that no one should disclose information regarding diagnosis, treatment, and prognosis. Consultation with the doctor and the husband will give critical information that may be relevant in understanding conditions that predispose the woman to trauma.
The third step of the model involves identification of ethical issues that are causing the dilemma. Susceptibility of the woman to trauma compels the doctor and the nurse to violate ethical principle of autonomy. As an advocate of patients, nurses have noble responsibility of ensuring that patients receive relevant information concerning diagnosis, treatment, and prognosis. In the case scenario, the nurse must ensure that the woman understands that diagnosis of her condition is gastric carcinoma and treatment is palliative operation that relieves pain. Moreover, the nurse needs to tell the woman that she will undergo treatment for a period six months according to prognosis of the doctor. However, due to susceptibility of the woman to trauma the nurse must act in accordance with ethical principles of beneficence and nonmaleficence. Ethical principle of beneficence demands that nurses should make decisions that promote health conditions of patients, while nonmaleficence ensures that nurses do not make decisions or perform actions that harm patients.
The fourth step in decision-making involves identification of personal and professional values that stakeholders hold regarding the dilemma. According to Gilliland (2010), ethical values are attitudes, beliefs, and opinions that influence how people perceive a given ethical dilemma (p.18). In the dilemma, the nurse believes that denying the woman information regarding her medical condition violates ethical principle of autonomy, which requires nurses to give essential information to patients so that they can make informed choices concerning their treatment. However, the nurse also has fears that disclosure of medical information to the woman may aggravate her condition since she is prone to trauma.
After identifying personal and professional values, the fifth step of decision-making involves consideration of the moral positions of stakeholders. The nurse must consider moral positions of other stakeholders before making conclusive decision. The moral position of the doctor is that disclosure of medical information as per stipulation of ethical principle of autonomy is detrimental to health status of the woman. Likewise, the husband also believes that disclosure can cause more harm than good to his wife. However, the woman feels that the husband and the doctor are hiding some vital information from her, and thus she believes that the truth will let her make informed choice about her illness and enhance her recovery.
Consideration of moral positions of stakeholders is essential in ascertaining sources of conflicts, which is the purpose of step six. In ethical dilemmas, conflicts can occur between or among individuals involved in dilemma. In the case scenario, the conflicts occur among the doctor, the woman, the nurse, the woman and the husband. One form of conflict occurs between the doctor and nurse. While the doctor believes that disclosure of medical information to the woman may aggravate her health condition because she has extensive fears of cancer and that she is prone to trauma, the nurse thinks that minimal disclosure of prognosis is essential to make the woman comfortable. Thus, interests of the doctor and the nurse are conflicting, hence complicating resolution of ethical dilemma. Moreover, there is a conflict between the nurse and the woman. The woman has immense fears of cancer, as she is not afraid of dying except that her condition is not due to cancer. Hence, she wants the nurse to reveal information of diagnosis, treatment, and prognosis, of which the nurse cannot reveal due to fear of traumatizing her more. Another conflict is between the husband and the woman because she feels that the doctor confides with the husband not to reveal some information to her.
Steps 7 and 8 enable nurses to pinpoint causes of ethical dilemmas and identify ways of resolving them. Step 7 entails determination of decision-makers. The doctor has the responsibility of determining the type and nature of treatment that a patient deserves while, on the other hand, the nurse has responsibility of determining the nature of care that befits the patient. Moreover, while the husband can play a significant role in convincing the wife to accept a given form of treatment, the wife has autonomy of choosing a certain form of treatment when given appropriate information regarding her condition. In step eight, the nurse needs to examine various outcomes of the numerous decisions that stakeholders support. In this step, the nurse should analyze outcomes to determine which among varied outcomes have minimal harm or prevent the occurrence of more harm.
Step 9 is the decisive step of decision-making. In this step, the nurse must critical examine varied outcomes and choose a decision that has greatest positive outcome. In this case, concealing of pertinent medical information is appropriate because it will improve recovery of the woman and prevent her from suffering undue stress due disclosure of shocking news regarding diagnosis, treatment and prognosis of gastric carcinoma. Ultimately, the last step is the evaluation of the outcomes of the decision taken to establish if the condition of the woman is improving or she still has some anxiety and trauma due to diagnosis, treatment, and prognosis of gastric carcinoma.
Conclusion
Nurses continually grapple with ethical dilemmas in the course of their profession because they have a noble role of advocating for the interests of patients. Despite the fact that ethical principles are there to guide nurses in resolving ethical dilemmas, complex ethical dilemmas require rigorous process of decision-making to resolve them effectively. In complex ethical dilemmas that involve patients, nurses, doctors and family members, bioethical decision-making model is appropriate for resolving them. The model is effective because it has a ten-step process that guides nurses to make appropriate decisions when resolving complex ethical dilemmas. Thus, a bioethical decision-making model is applicable in the resolution of complex ethical dilemmas that involve many stakeholders.
References
College and Association of Registered Nurses of Alberta. (2005). Ethical Decision-Making for Registered Nurses in Alberta: Guidelines and Recommendations. Alberta Association for Registered Nurses, 1-32. Web.
Gilliland, M. (2010). A Systemic Approach to Ethical Decision-Making for Nurses Confronted with Ethical Problems Involving Elder Abuse. University Health System, 16-23. Web.
Husted, J., & Husted, G. (2008). Ethical Decision Making in Nursing and Health Care: The Symphonological Approach. New York: Springer Publishing Company.
McGonigle, D., & Mastrian, K. (2011). Book Only: Nursing Informatics and the Foundation of Knowledge. New York: Jones & Bartlett Publishers.
Monagle, J., & Thomasma, D. (2004). Health Care Ethics: Critical Issues for the 21st Century. New York: Jones & Bartlett Learning.
Nasae, T., Suttharangsee, W., Ray, M., & Lynn, C. (2008). Ethical Dilemmas and Ethical Decision Making in Nursing Administration Experienced by Head Nurses from Regional Hospitals in South Thailand. Songkla Medical Journal, 26(5), 469-479.
Wilson-Barnett, J. (1986). Ethical Dilemmas in Nursing. Journal of Medical Ethics, 12, 123-135.
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