Ethical Issue: Refusal of Treatment

Introduction

The broad scope of nursing practice demands familiarity with the all of the ethical, professional and legal issues relating to clinical practice. The Nursing and Midwifery Council standards of conduct, performance and ethics require that nurses provide high standards of practice and have a duty of care to all patients (NMC 2007). This paper discusses the case of Alastair and explores the ethical, professional and legal issues which are of relevance to clinical nursing practice in this particular case.

Ethical, professional and legal issues

Autonomy is defined as the right to determine what happens to one’s own body. As stated by Mill (1982): “the only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him to do so, because it will make him happier, because, in the opinion of others to do so would be wise, or even right”. Every individual has a right to self-determination and patient autonomy forms part of that right and is protected by law (Hyland 2002). The principle of respect for autonomy forms a key component of nursing ethics (van Thiel and van Delden 2001). The nurse has an obligation to promote autonomy in the patient and work to empower the patient to make autonomous decisions where possible (Hewitt 2002). The Human Rights Act (1988) enables individuals to take action against a health authority that has failed to uphold their right to respect (OPSI 1998).

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Proot et al. (2002) described a study conducted in 27 health care providers from three different nursing homes, who were interviewed about autonomy issues relating to stroke patients in rehabilitation and nurses’ perceptions of patient autonomy. Study findings showed that self determination, independence and self care were all associated with the process of patients regaining their autonomy. In Alastair’s case, he was no longer independent and able to care for himself following his stroke, and had to rely on others for help with everyday activities. The nurse must therefore decide whether Alastair is capable of making a fully autonomous decision. If they believe this is not the case, they may be able to work with other members of the multidisciplinary care team to increase Alistair’s autonomy and empower him to make the best choices regarding his care.

Advocacy forms an integral part of a nurse’s role and is a mandatory activity within the ethical code of all professional nurses. Advocacy involves a professional responsibility to support the patient’s needs and wishes through active involvement in a process of analysis, counselling, responding, shielding and whistle blowing (Hyland 2002; Vaartio et al. 2006). There is a therefore a relationship between nurse advocacy and patient autonomy (Hyland 2002).

If nurses are to demonstrate paternalism and/or empower patients to make decisions regarding their care, they themselves must be empowered, particularly as nurses have increasingly greater accountability for their actions (Hewitt 2002; Christensen and Hewitt-Taylor 2006). The United Kingdom Central Council for Nursing Midwifery and Health Visiting states that “If the nurse does not feel that sufficient information has been given in terms readily understandable to the patient so as to enable him to make a truly informed decision, it is for her to state this opinion and seek to have the situation remedied …” (UKCC 1989). It is also suggested that advocacy may place the nurse in situations of conflict, since there may be differences between nurse’s and doctor’s perceptions of autonomy at times (Mallik 2007). Supporting Alastair’s wishes and his decisions regarding his care requires the nurse to possess knowledge of his condition and the likely consequences of discontinuing treatment. Through this empowerment, the nurse is ideally placed to educate and support Alistair in their role as advocate.

Beneficence (doing good) is central to nursing philosophy, but achieving a balance between this and non-maleficence (avoiding harm) can present a challenge for nurses and the two principles may be viewed as separate ends of one continuum (Bartter 2001). In Alistair’s case, the nurse must consider the benefits and risks associated with treatment and with discontinuing treatment, and explain these to Alistair, thereby allowing him to make informed decisions. In situations where the patient is unable to make an autonomous decision, the nurse has a duty of beneficence to act in the patient’s best interests, while also respecting the patient as an individual. This would apply if Alistair was deemed not to be of sound mind and decisions regarding his treatment had to made by his care team.

Veracity, or truth telling, is closely associated with informed decision making and is an important component of a trusting nurse-patient relationship. Veracity may present a dilemma for the nurse since there are times when telling the truth may cause harm to an individual (non-maleficence). Conversely there may be situations where telling a lie may actually do good (beneficence), although this goes against the principle of veracity (Ellis and Hartley 2003). The nurse has a duty to tell Alistair the truth about his condition and treatment to ensure that he is fully informed when making decisions regarding whether or not to continue with treatment/rehabilitation.

Justice as fairness in nursing refers to the need for nurses to treat people equally, although this does not necessarily mean treating them in the same way (Staunton and Chiarella 2005). Nurses must acknowledge cultural, social and educational diversity and adopt appropriate strategies to achieve equal treatment for all patients. Clinical governance demands the provision of high-quality, patient-centred care and Alistair’s individual situation and specific health needs must be taken into account by the nurse during his care.

All nurses, including those practicing within the community, have a duty to maintain confidentiality, although it should be acknowledged that there may be certain situations where confidentiality may be breached (Dimond 2000). Confidentiality is regarded as a critical component of good nursing care and reflects the professional responsibility of the nurse to respect a patient’s rights. The Data Protection Act 1998 also governs the protection of patients’ information (OPSI 1998). The nurse should therefore maintain Alistair’s confidentiality unless there is good reason not to do so.

Consent to treatment is central to the nurse-patient relationship and it is the patient’s decision alone as to whether they accept or reject treatment. As nurses broaden their scope of practice, issues surrounding patient consent to treatment are becoming increasingly important (Anon 1997). It is a principle of UK law that a competent adult who has passes the Re C test may refuse treatment even if his life depends on it (Dimond 2004). The Court of Appeal has stated that provided the patient has the necessary mental capacity (assessed in relation to the decision that has to me made), they can refuse to give consent with or without a reason for doing so.

In UK law, the court protects the right of the individual in this regard. This was illustrated in a case where the court ruled that “It is established that the principle of self-determination requires that respect must be given to the wishes of the patient, so that, if an adult patient of sound mind refuses, however unreasonably, to consent to treatment or care by which his life would or might be prolonged, the doctors responsible for his care must give effect to his wishes, even…though they do not consider it to be in his best interests to do so…” (Airedale NHS Trust v Bland [1993] AC 789). More recently was a case in which a woman paralysed from the neck down refused treatment in order to end her life. The woman was assessed to be of sound mind. The Court of Appeal ruling allowed a ventilator keeping the woman alive to be switched off, re-enforcing the duty of the healthcare professional to respect the wishes of a competed patient (Re B v NHS Trust [2002]). [Client: this case is similar to that of Alistair in that the patient was of sound mind and refused treatment. I was unable to find any cases relating to refusal of medical treatment in older adults of sound mind following stroke]

In the case of Alistair, he initially was receiving medical treatment but took a subsequent decision to refuse further treatment. An assessment should be made to determine whether Alistair is of sound mind and is capable of making informed decisions regarding his care. If he is indeed competent, the nurse should work to promote Alistair’s autonomy through education and other methods, taking into account the ethical principles of beneficence and non-maleficence, veracity and justice, to ensure that he possesses adequate knowledge to make the best decisions on his care. At present, Alistair’s health is reasonably good; however, his decision not to continue with treatment and rehabilitation is likely to have a negative impact on his health and well-being in the longer term. Both of the case laws described above are applicable to the case of Alistair, since, should this case reach the Court of Appeal and he is assessed as competent, the judge is likely to rule that Alistair’s wishes must be respected and his can continue to refuse treatment (based on the patient information provided in the scenario alone).

Conclusions

This paper has discussed the ethical, professional and legal issues relating to a specific patient case. It can be seen that these issues are inextricably linked and should all be taken into account in the provision of high-quality, patient-centred nursing care. In this case, self-determination, respecting the patient’s right to autonomy, and nurse advocacy are of particular importance, given that the patient is competent and capable of making informed decisions regarding his care. Other ethical principles including beneficence, non-maleficence, veracity and justice also play a key role in nurses’ ethical decision-making.

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