Nurses are faced with a lot of issues and dilemma in their work places. Nurses are committed to deliver services for all persons irrespective of color, background, social or economic status. They are committed to promote individuals, families, communities and national health goals in the best manner possible according to the code of conduct. Nurses are also involved in ethical, legal and political issues in the delivering of health care. Not all the time the nurses and doctors make decisions about the patient's treatment. The patients themselves have the right to decide whether they want the treatment or not. Nonetheless the duty to promote a patients best interest may conflict with the duty to respect the same patient's autonomous wishes concerning treatment. This can lead to legal issues and the nurses and doctors have to follow the four principles approach. The four principles is one of most widely used frameworks and offers a broad consideration of medical ethics issues generally, not just for use in a clinical setting, The four principles are general guides that leave considerable room for judgment in specific cases. (Study Skills Notes)
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The four principles are: THE RESPECT OF AUTONOMY. The principle or respect for autonomy entails taking into account and giving consideration to the patient's views on his/her treatment regardless of their competent. This self-rule is limited by the particulars of events that may render some choices to be merely apparent autonomous choices. An example may be that a person's choices are influenced by illicit drugs, medication, disease processes or just the plain influence of another person. In some cases people who have been physically or sexually abused sometimes hide the true nature of their abuse or abuser. However, in this instance respect for autonomy involves not only ‘acknowledging decision-making rights but enabling persons to act automonously.'(Beauchamp and Childress 2001:pg63).
THE BENEFICENCE means to do good in Latin. The healthcare professional should act to benefit patient or client. This principle may clash with the principle of respect for autonomy when the patient makes a decision that the healthcare professional does not think will benefit the patient. It is clear that the nature of the relationship between health professionals and their patients establishes an obligation of beneficence. This obligation is frequently referred to as a duty of care. However, a duty of care is clearly also influenced by other principles.(Beauchamp and Childress 2001:pg225-275)
NON-MALEFICENCE: Do no harm. As a justification for condemning any act which unjustly injures a person or causes them to suffer an otherwise avoidable harm. For example, if a patient suffers an infection from a bacteria like methicillin (or multidrug)-resistant or MRSA because health care workers fail to take precautions such as properly washing their hands then that would be a breach of principle of non-maleficence.(Beauchamp and Childress 2001:pg225-275)
The fourth principle is JUSTICE: is the most difficult and elusive of the four principles. One of conception of justice is termed ‘distributive justice.' This concerns for instance the just distribution of benefits such as state funded health care. All distributions conform of justice that equals should be treated equally. Justice means fairness not postcode lottery. Each member of society, irrespective of wealth or position, should have access to healthcare. However only those of health care that achieve or have priority. Such as emergency care or treatment for acute phases of illness or perhaps preventative health measures, education may be included in state-funded health care but purely cosmetic surgery or artificial fertilization treatments may not be included. (Beauchamp and Childress 2001:pg225-275)
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Like in this lady's case a 76 year old named Betty suffers from a continuous intestinal obstruction following a bowel perforation resection which means (a broken or burst bowel). She has been chrormically unwell for a long time and has had recurrent chest infections and sepsis. She has been admitted to intensive care on at least four occasions in the past year. On each occasion, despite predictions to the contrary, she has been well enough to return home. She was admitted again for the fifth time to intensive for an operation prior to another laparotomy. This time she had heard enough so she refused treatment. They then transferred her to an ordinary ward for nursing care with instructions for the nursing staff that she is to be kept comfortable but is not for further active treatment. But Betty's daughter who is a doctor and lives abroad flown in and was adamant that everything possible should be done for her mother. She asks for her mum to be returned to intensive care and be given the treatment. Betty's son who lives locally and has been her main carer said his mother has been through enough and does not want her to have any further active intervention. That's when the four principles come in. Betty has to be assessed to see whether she is competent then maybe persuade her to rethink if that doesn't work they just have to respect her wishes. If Betty lacks capacity her views about the care she receives are important in determining her best interests. The clinician may feel that he/she is not acting beneficently towards his/her patient if he/she allows her to die for lack of treatment. With all that involve there will be tension between beneficence and non-maleficence in such a case. Betty's son views are also important because he has been there for his mum regarding her wishes. In Betty's case the law a competent person refusing treatment to put it in writing and witnessed. The Act enables a person when competent to appoint a proxy to take healthcare decisions for her when she loses capacity. This can be done through a Lasting Power of Attorney, a formal document that must be lodged with the Court of Protection. (Ethic education resource pack: Ethic and the vulnerable patient Ethox Centre 2005)
According to the Nursing and Midwifery Councils' Advocacy and Autonomy. Every patient has the right to make their own decisions regarding their health care. "As a registered nurse, midwife or specialist community public health nurse, have to respect the patient or client as an individual." Advocacy is concerned with promoting and protecting the interests of patients and clients, many of whom may be vulnerable and incapable of protecting their own interests. They may lack the support of family and friends. (NMC Advocacy and Automomy).
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