This assignment aims to critically appraise an ethical conflict in relation to the care provided to a patient. It will explore how ethical decisions are reached and how they can directly influence patient care. To achieve this aim the author will examine a case study of a patient whose care he was involved with whilst in placement.
We will look at how, after an episode of self-harm, the patient refused any medical treatment for the wound and how this posed an ethical dilemma for the nursing staff involved in their care. Using the application of the Mental Capacity Act (MCA) (Great Britain (GB) 2005) and an established model for ethical decision making, we will look at how the decision of whether or not to enforce treatment for the wound was formulated and actioned.
Ethics can be seen as the study of human conduct and morality (Buka 2008). It is about people reasoning, thinking and applying a process of reflection (Adshead 2010); however these people may have opposing views, values and experiences on which to base their moral judgements to define what is the right and wrong course of action (Hendrick 2009) and the principles used to decide this, not only by the individual but also within social groups and societies. (Adshead 2010). From this we can surmise that ethics is a complex system of reflective thinking, which is used in the search for a standard that can be used to judge your own actions, or the actions of others, within your own moral code.
The Nursing and Midwifery Council (NMC 2008) stipulates that nurses must respect a patients right to confidentiality at all times and ensure that the patient is informed about how information concerning them is shared. In accordance with this the name of the patient has been changed and permission has been sought from the patient to use them in the case study (Appendix 1).
Anita is a young woman with a primary diagnosis of emotionally unstable personality disorder borderline type as defined by the World Health Organisation (WHO 2010). During a one-to-one therapeutic session Anita disclosed that she was having strong urges to self-harm. As such the therapeutic session concentrated on exploring her feelings surrounding her impulses, alternative coping mechanisms to manage her thoughts of self-harm and strategies to help maintain her safety upon the ward.
As she felt that the pressure of being constantly watched would unsettle her further, thus not allowing her to manage her own feelings it was initially agreed to place Anita on intermittent observation as opposed to constant within the policy on self harm produced by the service that was caring for her (Oxford Health DATE). This approach was agreed in collaboration with Anita and the wider team as a way of her taking responsibility for her own decisions.
Later in the shift Anita approached staff and stated that she had overwhelming urges to self-harm and that she had acted upon them. She was taken to the clinic room where the wound could be cleaned and assessed. Anita presented with a laceration to the inside of her thigh which was deep enough to expose the adipose tissue beneath, however was not deemed by the medical staff to be life threatening.
Staff explained to Anita that the wound was deep enough to require stitching although not life threatening and advised her that she would need to attend the minor injuries unit of the local general hospital for assessment of the wound. At this time Anita, due to her mental state, could not fully appreciate the nature of the wound and felt that she needed to punish herself further by refusing treatment. The nurses on duty cleaned and bandaged the wound and allowed Anita time to consider the implications of her decision further. When Anita had calmed the nurse had a discussion surrounding the implications of not having the wound sutured such as infection, Anita's possible need to attack the wound in the future and pain relief issues, However Anita maintained her decision not to have the wound sutured.
Following a wider team discussion around whether Anita understood the severity of the wound, thus having capacity to make a decision to refuse treatment, the Responsible Clinician (RC) spoke to Anita and attempted to persuade her to have the wound sutured. As Anita was still refusing to have the wound sutured the RC decided that an assessment would need to be carried out to ascertain whether Anita had the capacity to decide to refuse treatment. Upon completion of the assessment it was decided that Anita did have capacity to make decisions surrounding treatment at that time, within the framework of the Mental Capacity Act (GB 2005). This decision was reached due to Anita being able to understand the information being given to her, being able to retain the information and weigh it up to make a decision to refuse treatment.
Although this appeared to be an unwise decision, which felt uncomfortable to the team, it was agreed to monitor the wound, keep it clean and dry and continue to talk to Anita about her thoughts and feelings surrounding getting medical treatment for the wound. This collaborative approach allowed Anita opportunities to explore her emotions, thoughts and feelings and promote her autonomy whilst still allowing her to decide to have the wound sutured should she change her mind.
The main legal and ethical dilemmas that can be extracted from this case study are whether the Anita's capacity to make decisions about her treatment should be overridden by use of the Mental Capacity Act (GB 2005) and whether Anita's ability to make autonomous decisions surrounding her care should outweigh the nurse's obligation towards beneficence.
The Legal Dilemma. Mental Capacity.
What legal Dilemma can be hypothesised as underpinning the decision making process of the mental health professionals in this case? Anita initially made her decision to refuse treatment shortly after self-harming. Self-harm has been strongly associated with borderline personality disorder (Motz 2008) where thoughts of self-loathing and self-punishment are common precipitators; the act of self harm can be seen as a symptom of internal turmoil, an expression of internal pain or as controlling factor to maintain a level of care (Grocutt 2009). This may indicate that Anita was under a great deal of distress at the time, which could have affected her capacity to make sound decisions; however her later decision of continuing to refuse treatment was based on her own morals and values towards her body that may have included these thoughts of self-loathing and the need to be punished. Although a person, under part four Mental Health Act (GB 2007) can be treated for mental disorder without their consent, it is important to note that a physical problem can only be treated without consent should the person lacks capacity and treatment is deemed to be in their best interests under the auspice of the Mental Capacity Act (GB 2007, MIND 2009).
To help determine whether Anita has capacity, The Mental Capacity Act (2005) sets out a two stage functional approach. Firstly the practitioner needs to ascertain whether the person being assessed has some sort of disturbance of the mind and, if such a disturbance exists then it "must affect their ability to make decisions when they need to" (Department of Constitutional Affairs (DoCA) 2007:45). If this is not the case then the person cannot be seen as lacking capacity under the Act (GB 2005, DoCA 2007). In considering whether Anita needed to make the decision around treatment, we can see that, as the wound was not life threatening, it was decided to allow her time to settle and re-approach the question of treatment. The Mental Capacity Act (GB 2005) is clear in expressing that capacity is time and decision specific. In deciding that the decision could be made at a later time not only complies with the Act but also promotes Anita's autonomy. As the wound could be safely managed in the short term upon the ward the decision to allow Anita time to weigh up the information was the correct one to make.
Conflicting ethical principles and dilemmas
Lakeman (2009) points out that an ethical dilemma occurs when there are a multitude of alternative courses of action to deal with a particular situation. Conflicting moral principles may create difficult ethical dilemmas for nurses by having to contravene one moral obligation to uphold another (Beauchamp & Childress 2009). Anita's ability to make autonomous decisions surrounding her care should outweigh the nurse's obligation towards beneficence. However this may not feel entirely comfortable for the nurse. In mental health nursing, autonomy is sometimes overridden in the interests of promoting the principle of beneficence (Lakeman 2009). Which can make the nurses ethical dilemma difficult to manage due to balancing the two valid ethical principles of autonomy (respecting and supporting decisions making) and beneficence (relieving or minimising harm in the best interest of the patient) (Hendrick 2004, Beauchamp & Childress 2009). To answer the question we need to examine how the dilemma sits within an ethical theory and the principles that apply.
Beauchamp and Childress (2009) devised four basic moral principles which function as guidelines for professional ethical decision making. The principles of autonomy (freedom to act on your own belief), Nonmaleficence (obligation to avoid doing harm), Beneficence (providing benefits and help) and Justice (fair distribution of benefits, risk and cost) which are derived from a duty based theory of Emmanuel Kant (1724-1804) (Beauchamp & Childress 2009).
Principle 1 Autonomy.
Respect for autonomy flows from the recognition that all persons have unconditional worth, each having the capacity to determine his or her own moral destiny. To violate a person's autonomy is to treat that person merely as a means: that is, in accordance with others' goals without regard to the persons own goals.
Beauchamp & Childress (2009: 103) after Kant
Autonomy is "the freedom and ability to act in a self determined manner" (Butts & Rich 2008: 42) and the right of a rational person to achieve personal decisions without any outside interference. Therefore the principle of respecting autonomy concerns the nurse's acknowledgement of, and obligation in respecting, Anita's decision over her own life.
It may be that Anita is already feeling a loss of autonomy or disempowerment by the very nature of being a patient upon a secure ward and being under the Mental Health Act (GB 2007) and the restriction of her basic autonomous decisions such as when to eat, sleep or who she resides with. Therefore it may need to be considered whether Anita's is refusal of treatment is something that she feels in control of, thus a way in which she feels empowered.
Principle 2 Beneficence.
Morality requires not only that we treat persons autonomously and refrain from harming them, but also that we contribute to their welfareâ€¦ and â€¦[is therefore]â€¦ a moral obligation to act for the benefit of others. These beneficial actions fall under the heading of beneficence.
Beauchamp and Childress (2009: 197)
Beneficence can be seen as actions to benefit and promote the welfare of others (Butts & Rich 2008). All actions that are performed by nurses can be regarded as having a moral dimension, most of which are for the benefit of the patient (Edwards 2009).
The NMC Code of Professional Conduct is clear in stating that nurses have an obligation to both protect and promote the "health and wellbeing" of patients as their primary consideration (NMC 2008:2) and this is no different for mental health nurses working with patients who self-harm. This statement clearly incorporates the principle of beneficence and shows that the nurses in the case study are considering whether Anita should have medical treatment for the wound enforced upon her due to the principle of beneficence as described due to the worries of the wound becoming infected if not sutured.
When nurses experience the ethical dilemma of having to enforce treatment irrespective of a patient's right to autonomy, they can be seen as working in a paternalistic manner (Butts & Rich 2008). In Anita's case, the nurses worry that the consequences of the wound becoming infected is driving their desire to treat the wound irrespective of Anita's wishes. However, although the actions on behalf of nurses is clearly driven by obligations towards beneficence, nurses need to weigh up the harms and benefits of enforcing treatment before acting in such a way as to produce the best outcome for Anita (Edwards 2009). A paternalistic approach is frequently used to infringe upon a person's right to autonomy. This infringement is "supported by the principle of beneficence, which is the argument frequently used to impose treatment on patients whether they want it or not" (Buka 2008: 29).
Should the decision to treat Anita for her self harm regardless of her wishes have gone ahead, there may have been a risk of impacting on the nurse-patient therapeutic relationship. This relationship is built upon trust as well as purposeful and effective communication (Buka 2008) and is considered to be the cornerstone of nursing care (Lakeman 2009, Pryjmachuk 2011).Therefore the nurses would need to consider future risk as part of the ethical decision making process. Enforcing treatment on Anita may produce barriers to the therapeutic relationship such as difficulties in trusting the nurse in the future, disengagement from therapeutic communication, opposition and rejection of future treatment, increased self harming behaviours due to the trauma and hostility towards others (Kettles et al 2007, Byrt 2010), all of which may stop Anita from telling the nursing team when she self-harms in future episodes of distress. Which raises the principle of Nonmaleficence (doing no harm), in this instance to the therapeutic relationship, wellbeing and care of Anita.
The decision to manage the wound on the ward and allow Anita time to calm and consider her options is, in the author's opinion, the correct course of action to take. As the wound was neither life threatening or of such a degree that it could not be safety managed upon the ward enabled the staff to consider the possibility of allowing Anita to make an autonomous choice. In considering Anita's wishes and agreeing a management plan to care for the wound incorporates both principles of Anita's autonomy and the nurse's obligation towards beneficence.
Beneficence could be interpreted to incorporate the patient's autonomous choice as "the best interests of the patient are intimately linked with their preferences ... [from which]â€¦ "are derived our primary duties towards them" (Beauchamp & Childress 2009:207). If the nurse's obligation to act beneficently is informed by the patient's choices and preferences, then the respect for the patient's autonomy will ultimately override any paternalistic actions on the part of the nurse (Beauchamp & Childress 2009). This would not only encourage a supportive nurse-patient relationship but also provides care that is holistic, develops Anita's confidence in being able to negotiate her care and allows her to take greater personal responsibility, thus instilling empowerment and hope, all of which improve the potential for recovery.
The practice of paternalism is now generally discouraged in health care (Butts & Rich) and is considered unjustifiable in cases where the patient has capacity to make a decision (Edwards 2009, Beauchamp & Childress 2009).
Every decision that a nurse makes concerning the care of a patient needs to be considered from an ethical base. Any decision made from this ethical viewpoint has a higher probability of producing the best outcome under any given circumstance.
The conflicting principles of autonomy and beneficence that have been presented within this case study would both be ethically and morally correct courses of action to take. From this we can surmise that a morally correct course of action may involve two opposing principles being applicable in any one situation.
Are large proportion of moral and ethical dilemmas that are faced by nurses stem from the conflicting principles of autonomy and beneficence. However, the nurse's ability to critically appraise risks and benefits will help them to make decisions that are beneficial to the patient involved. In encouraging autonomy for Anita involves taking risks on the part of the nurses' which may go against their principles of Nonmaleficence and beneficence. However with collaborative working practices this case study has shown that solutions can be found in even the most complicated of nursing dilemmas.