“Am I dying?” these words gave me goose bumps when I was asked by one of my terminally ill patient who was diagnosed with an inoperable tumor. These words echo in my ears whole shift. However, I always decided to keep myself quite or sooth my patient with false hopes. I was restricted by the medical staff and the family that the patient is not to be told about her prognosis. This type of dilemmas arises very frequently when we talk about health care ethics. In this paper I will discuss and analyze the four principles of Beauchamp and Childress in the light of above shared case scenario.
The Ethical Dilemma
The above case scenario presents a dilemma when the nurse has to choose between the mutually exclusive events (Beauchamp & Walters, 2003). In this case the conflict is between the principle of respect for patientâ€™s autonomy, principle of beneficence, non-maleficence, and justice. Principle of autonomy entails to be truthful to the patient. On the other hand, beneficence obliged nurse to do good to patient and prevent patient from harm. In this case the medical team and family insist nurse not to disclose the diagnosis because they might have anticipated that knowing the diagnosis will make patient depress and as a consequences the patient might not try to get better or lose hope, whereas nurse is breaching patientâ€™s autonomy by hiding the truth. This decision of telling truth to patient may result in undesirable outcome for family and medical staff while, giving priority to familyâ€™s wish may result in undesirable outcome for patient.
The Patientâ€™s Bill of Rights asserts that it is the responsibility of every health care provider to give patients correct information and that patients ought to agree to treatment (New York State Department of Health, 2008). However, the four principles of Beauchamp and Childress always remains the dynamic force in the modern bio ethics.
Compare and Contrast in the view of four ethical principles of Beauchamp and Childress
Respect for Autonomy
All ethics flows from the principle of autonomy or as Childress and Beauchamp have it, respect of patientâ€™s autonomy. It is remarkable to note that principle of biomedical ethics begin with the dialogue of autonomy. According to Beauchamp and Childress (2001) “â€¦our order of presentation does not imply that this principle has priority over all other principles. A misguided criticism of our account is that the principle of respect for autonomy overrides all other moral considerations. This we firmly deny.” Autonomy means to make a decision for the self without the control of others and a person can make meaning choices having sufficient level of understanding (Lawrence, 2007). In this case scenario the patient has full rights to be known about her condition regardless of the control of family and medical team. Moreover, if the nurse would disclose the prognosis the patient will be able to make autonomous choices about her treatment plan. Also, the patient in our case is not incompetent nor has any mental disability and can take decisions on her own.
Another ethical dilemma arises in this case scenario is, to what level is it ethically right to share patient information with the family when the patient is in a state of receiving and processing the information. The answer to this question is that the primary responsibility of the nurse is patient. It is important to understand that being autonomous gives patient freedom to choose about her own treatment options and also prevents nurse from providing false assurance to patient.
The principle of beneficence requires that patient autonomy should be respected. Determining good is always an individual choice and the good that client can decide can often vary from that of her medical team or family. Beauchamp and Childress (2001) explicate two types of beneficence i.e. positive and utility. Positive beneficence means that client should provide with benefit, while utility means to weight risk and benefits and decide on the best result. Though, No one can weigh what is good for patient except patient herself.
Beneficence in this case can also be considered by the nurse to justify the disclosure of poor prognosis of inoperable tumor to patient. Even the patient prognosis is poor the patient may need to know it so that to complete undone businesses to gain a sense of finishing her lifeâ€™s work. Disclosure of diagnosis may let patient to change her attitude towards life by putting forward new aims and work on accomplishing them in their remaining life. Revelation of correct prognosis will also help patient to gain peace of mind and this will also decrease patient worries. However, breaking poor prognosis to patient might have a great significance to patient that should not be withhold. Therefore, beneficence overlap with autonomy, clientâ€™s wish to be informed about her prognosis, and may wish to select on particular option for her care as in her view that is the greatest good.
On the other hand, do no harm is the negative side of the beneficence. We can also say that beneficence and non-maleficence are the two sides of the same coin. We can look at the notion of avoiding harm from the era of Florence Nightingale; therefore nurse should consider every possible risk that could potentially occur. The aspect of not telling truth in this case scenario relates to the principle of non-maleficence. Telling truth to the patient about poor diagnosis may cause possible harm or psychological distress to patient. Furthermore, Hope is an important aspect to deal with such life threatening conditions with poor prognosis and revealing truth can abolish patientâ€™s hope. Therefore, in such situation withholding truth from patient may enhance patient care.
Itâ€™s an obligation to nurses to be honest with their patients. Beneficence or respect patientâ€™s autonomy by telling truth (veracity) is also important as it is the right of the patient to have full knowledge about her prognosis. However, if the chance to harm the patient in this situation is greater like psychological trauma than harm should be avoided first. This requires nurse to be skillful enough in assessing the net benefits and net harm that is being provided to patient. Moreover, nurse should demonstrate empowerment in order to take decision in patientâ€™s interest (Stanley, 1998). Another aspect of not telling truth can break the therapeutic relationship between nurse and patient. However, if accidently patient got to know about her prognosis she might end up in serious complications like self harm or suicidal attempt. Therefore, before reaching to conclusion nurse must consider in-depth situational analysis.
Conn, Gillam and Conway (2005) describe two forms of justice i.e. distributive justice and the rights based justice. The rights based justice refers to the respect of people’s rights rather than the law. In health care industry, it is individualâ€™s right to seek health care and contribute in their treatment plan. Justice in this case scenario refers to the respect of patientâ€™s right and respect for morally accepted laws (Lawrence, 2007). Justice and duty are the underlying moral principle for nurse to follow in making any ethical decision. Based upon deontology a nurse should accept the obligation and duty of her role in order to do justice. Telling truth and giving full information is a nurse duty to follow therefore, by deceiving patientâ€™s information and giving false hopes is the violation of her duty. Moreover, the principle of justice also requires a nurse to provide adequate health care. This includes providing right information to patient, while refusing to tell patient about her prognosis the nurse is violating the principle of justice and disrespecting patientâ€™s right.
Another view point in this case scenario is the paternalistic approach of the medical staff and the family members. This approach means to have a protective attitude towards other. Also, it should be driven by the principles of beneficence and non-maleficence. Justifying paternalistic intervention in this case scenario is necessary. In the light of Benjamin and Curtis (1986) firstly, the patient is terminally ill but her condition is not significantly impaired and patient has the capacity to rationalize the reflection about her condition. Secondly, the patient could suffer from psychological distress but keeping patientâ€™s wish and autonomy in mind nurse should do proper assessment from patient and from family members in order to take correct decision. Thirdly, the terminally ill patient can never ratify that things which were decided on her behalf were against her wishes. In actual fact, the patient with last few days might regret that if she has known about her prognosis, she would have fulfilled her wishes or spent more time with the family. Therefore, paternalistic approach in this case scenario seems to have low weighted.
Compare and Contrast in the View of Ethical Theological Theories
Theological theories focus on outcomes of the actions. The action is said to be ethical if the action causes good effect. If we look at the scenario in the view of utilitarianism theory, Nurse by not telling the prognosis to patient is ethically right. It says to do utmost good for the maximum number of people and the individual interest is secondary. By not respecting patientâ€™s autonomy to be informed about her diagnosis; nurse is performing her job in the interest of family as well as medical team. On the other hand, if nurse follows the theory of existentialism she is not free to take her own decision and tell patient truth about her prognosis. In this case, nurse is free to take her own decision not following any laws or code of ethics while ethical reasoning can be absent in this case. However, nurse should judge this scenario in the view of pragmatism which inculcates to consider useful and practical solution in given situation. In my judgment the practical solution to this case scenario is to reveal the diagnosis to patient taking consideration of all the circumstances and give right to patient to choose her own treatment plan.
To comprehend the decision making process in the above mentioned case scenario, nurse must consider the principles of autonomy, beneficence, non-maleficence, justice along with patientâ€™s respect and compassion. According to Gardiner (2003) all the ethical principles should influence oneâ€™s choice. In this case, the medical team and family suspected that after knowing the prognosis she might experience psychological distress.
The contextual factors in this case centered on the violation of patient autonomy and doing non-maleficence. The patient keeps asking the nurse “Am I dying?” In this case the nurse should draw a decision from the code of ethics by honoring patientâ€™s wish and by understanding clientâ€™s perspective. The American Nurses Association, code of ethics defines that “The nurse provides services with respect for human dignity and the uniqueness of the client, unrestricted by considerations of social or economic status, personal attributes or the nature of the health problem” (ANA, 2001, p.1). To respect the patientâ€™s decision and honour her dignity, correct information should be provided to the client in an effort to justify her rights, while respecting her wishes at the same time.
In conclusion, it is hard to justify the discussion because the above mentioned case scenario arises from the argument between the four ethical principles of autonomy, beneficence, non-maleficence, and justice. In my judgment, the nurse should focus on patientâ€™s autonomy and her right to select what she supposed best despite the possible outcomes. Moreover, after consideration on number of ethical theories, it can reluctantly be concluded that patient autonomy should be respected at first. Along with this the situational analysis of situation is equally important to be considered before reaching to any solution. In nursing practice, such situations like forced to hide bad news to patients are becoming very common. Therefore, it is important for every health care professional to understand ethical principles and act accordingly. This requires a proper system that need to there for an ethically informed decision. This includes ethical committee having medical doctors and nurses so that ethically sound decision could be made in the best interest of patient. Also, it is the ethical responsibility of the nursing faculties to prepare competent nurses, and hospitals should facilitate continuing education for nurses so that they can recognize and resolve ethical dilemmas by applying ethical principles.