Ethical Decision-Making in the Nursing profession
Ethics is defined as ."..the basis on which people...decide that certain actions are right or wrong and whether one ought to do something or has a right to something"(Rumbold, 1986). As far as ethics is concerned in nursing services, "Nursing decisions affect people... nurses have the power to good or harm to their patients" (Bandman et al, 2002). This essay is intended to highlight the most imperative ethical pinpoints and ideas of the case of Evan--a Scottish hospital patient--will stage out the varying levels of possible outcomes and decisions utilizing DECIDE Model for Ethical Decision-Making as outlined by Thompson et al (2000), and will declare a position on the best possible decision that could be made as a nurse in this situation.
In "Defining the Problem", the initial step that in one's tactical approach in ethical decision-making, the highlighted fundamentals are that Evan is a patient commited to a psychiatric hospital, he is also a married (to a woman) man who contracted HIV during a homosexual relationship of which his wife is unaware. With regards to this, he is adamant that his wife not be told about his medical illness. The stakeholders involved directly are: Evan, who does not want his family to find out about his illness or affair; his nurse, who is under increased strain worrying about the burden of, perhaps, having to break the confidentiality entrusted in him; Claire, is the most direct stakeholder as she may have contracted HIV; Evan's partner during the affair is also at risk of contracting HIV and his subsequent partners are also at risk; the other members of staff, are in constant worry over Evan which means that they cannot concentrate fully on their other patients; Evan's family is also involved directly as they are worried about his well-being. There are also stakeholders indirectly involved in this case. They are the patients, who may not be receiving sufficient care if the staff is so entwined in Evan's case. Evan and the other patients have a right to confidentiality; therefore, legally his HIV status cannot be disclosed to the other patients (HIV/Psychiatric manual, 1997). In assessing Evan's rights and the duties of the nurse, Evan has a right to confidentiality, trust, informed treatment decisions and quality care. An Bord Analtrais "Code of Professional Conduct" (2000) states that the nurse is obliged to dutifully undertake these rules. However, Claire's health and that of the former partner are at stake. The nurse will break the confidentiality and trust rules by telling Claire of Evan's illness. The nurse has a responsibility towards other professionals therefore informed decisions and quality care will not be carried out until information of Evan's HIV status is divulged. The last aspect of "Defining the Problem", is to recognise the main ethical problem to be addressed which is whether or not to dismiss patient-nurse confidentiality and trust in order to get adequate healthcare for Claire and Evan's other partner.
In identifying the principles and concepts of Evan's case, the author will use "Ethical Review", the second stage of one's approach to ethical decision-making, in conducting this element of the ethical analysis of Evan's case. The most important ethical principle is "respect for autonomy" which .".. generates an obligation to respect the choices which others make concerning their own lives" (Edwards, 1996). In respecting Evan's dignity the nurse must remain confidential about his illness. However, truth telling is considered as non-negotiable, legally and morally, as the well-being of Claire, Evan's partner and the sufficient care of Evan is the focus of the consequences of the nurse's breach of confidentiality. The next principle is that of 'beneficence'. This principle .".. generates an obligation to act in ways which promote the well-being of others" (Edwards, 1996). The nurse is promoting Evan's health by giving him treatment for HIV. However, as Evan's wife and family are unaware of his HIV status, Evan is suffering with a guilty conscience, which will only promote a pessimistic outlook. The quote says to ."..promote the well-being of others..." including Claire, and Evan's previous partner. By committing to confidentiality, the nurse is not promoting the good health of Evan, Claire or the other partner. The next principle in this case is 'nonmaleficence'. "As a registered nurse...you...must: ensure that no action or omission on your part, or within your sphere of responsibility, is detrimental to the interests, condition or safety of patients and clients" (UKCC, 1992). This deals with the rule that no patient should be physically unsafe in another's care. Evan is in safe hands but the hands of his nurse are bound by the confidentially rule. Claire and Evan's other partner are at risk of being physically harmed, as they are still not receiving treatment. The final principle, 'justice' "generates obligations to treat others fairly" (Edwards, 1996). There is very little justice being given to Claire. Both the health system and her own husband are unjustly lying to Claire. As the nurse is becoming more conscious of the moral decision he must make, it is causing Evan to slip into further denial about his HIV status. ."..He behaves as if nothing has happened...he mainly talks about what they will do together when he gets out of hospital..." and is increasing the threat to her health and Evan's other partner. In this case study, there are important concepts in relation to nursing ethics. There is an issue of 'advocacy', which is very sensitive in this case ."..because without advocacy...there are no rights (Bandman et al, 2002). Evan needs the nurse to be his advocate and uphold his right to confidentiality. There is also an issue of 'caring' in this case. "Caring is a form of doing good and avoiding harm and thus...is central to nursing ethics" (Bandman et al, 2002). Evan is currently under psychiatric care and his guilty conscience is having a detrimental affect on his well-being. The nurse is being ignorant of the threat to Claire and Evan's partner's health by not promoting their interests.
"Considering Options", is the third stage of one's approach to ethical decision-making. At least one option would consider breaking the confidentiality code instilled in nursing care. One option would be to respect Evan's autonomy and continue to treat him for HIV without the knowledge of his wife and family. The second option would be for the nurse to tell Claire about Evan's HIV status and to advise her to have a HIV test done. The third option would be to empower Evan and then for Evan to tell her of his HIV status. The last option would be to tell the doctor in charge of Evan to tell Claire or, pass it onto her own physician to tell Claire. The nurse would require help from a counsellor in encouraging Evan to tell Claire about his HIV status. The nurse should not take this situation into his own hands and should consult the help of both Evan's and Claire's physicians on how best to approach a decision.
"Investigating Outcomes", is the fourth stage of one's approach to ethical decision-making. The only advantage of not telling Claire about Evan's illness is the fact that the nurse would be respecting his autonomy. There are many disadvantages to the consequences of this action. Claire would continue to go untreated for HIV, as would Evan's partner during the affair. The affects of untreated HIV would erupt into full-blown AIDS, which leads to death. One disadvantage of the second option is that the nurse would be breaking the confidentiality code instilled in the nurse-patient relationship. The main disadvantage is that, legally, it can only be the physicians of Claire or Evan, public health authorities or Evan himself that can notify Claire that she is at risk at having contracted HIV (HIV/Psychiatry Manual, 1997). Options three and four would be the most feasible as they are legal and promote the well-being of all parties. Option three is one disadvantage as it could take a long time to persuade Evan to tell his wife about his illness. Option four would be much faster in dealing with the situation and people would be more likely to see the moral reasoning behind the doctor telling Claire that Evan has HIV than the nurse. Doctors are still regarded as more 'professional' and their decisions are seen as more superior and morally right.
"Decide on Option" element of the DECIDE Model, is the fifth stage of one's approach to ethical decision-making. The author decided that consulting with a counsellor and the physicians of both Claire and Evan was the best way to get across how the author felt that this sensitive case should be approached. Their opinions would be invited but the author felt that, as it was the most legal and quickest method, the doctor should tell Claire about Evan. Claire could receive treatment and counselling immediately and the nurse could tell Evan that his wife now knew about his illness. He would probably need more counselling for a time afterwards, especially if his wife decides that their relationship is over. Her counsellor would advise her to support Evan as he too is in a sensitive state of mental well-being.
While using the "Evaluate Results" element of the DECIDE Model, the final stage of one's approach to ethical decision-making, the author decided that in ."..sacrificing...own greatest good for the good of others..." (Mill, 1861 cited in Price, 2000, p299), one remained true to one's character, which is central to the provision of care. The author heavily weighed up the consequences of having Evan's physician tell Claire that her husband was HIV positive and it was a massive moral consideration. In conducting an ethical analysis, the author identified the most important ethical principles of Evan's case, outlined the different stages of one's ethical decision-making by employing the use of the DECIDE Model and decided upon particular actions one would take as a nurse in this situation. ."..According to Utilitarian, acts are right in so far as they maximise benefits or minimise harms" (Edwards, 1996).
American Nurses' Association. (1997) Chapter 18: Legal and Ethical Issues in HIV. The HIV/ Psychiatry Manual.
An Bord Analtrais. (2000) The Code of Professional Conduct.
Bandman, E., and Bandman, B. (2002) Nursing Ethics: Through the Life Span. 4th ed. New Jersey: Prentice Hall.
Edwards, S.D. (1996) Nursing Ethics: A Principle-Based Approach. 1st ed. Hampshire: Palgrave Macmillan.
Mill, J.S. (1861) Utilitarianism. Cited in Price, J.A. (2000) Philosophy through The Ages. 1st ed. Australia: Wadsworth.
Rumbold, G. (2000) Ethics in Nursing Practice. 3rd ed. Edinburgh: Bailliere Tindall.
Tadd, W. (2004) Ethical and Professional Issues in Nursing. 1st ed. Hampshire: Palgrave Macmillan.
Thompson, I.E., Melia, K.M., Boyd, K.M. (2003) Nursing Ethics. 4th ed. Edinburgh: Churchill Livingstone.
UKCC (United Kingdom Central Council for Nursing, Midwifery and Health Visiting) (1992) Code of Professional Conduct for the Nurse, Midwife and Health Visitor, 3rd ed. London: UKCC
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