My topic is regarding a nurse should respect the ethical principle of autonomy whereby allowing patient to make decision free willingly and should not lie, but carry out the ethical principle of truth-telling(veracity) to patient by informing the full and true information about the proposed treatment.
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The main problems identified in this case study of Jill and Marie is the followings. Firstly, autonomy was not present whereby Marie was not given the choice to choose to accept or refuse the proposed treatment. Secondly, truth-telling whereby, is the giving of true information regarding the proposed treatment without lying to the patient. Thirdly, informed consent was not taken where Marie was allowed to make her choice with freewill. Fourthly, as a nurse Jill has breached in the standard of care by threatening the patient to treatment.
By reading through the literature of the case study some facts was found. It was presumed that Marie is capable to make her own consent for treatment since she is 18 years old and has the cognitive capacity to understand all the aspects of the proposed treatment, but this privileged was being taken away. It was also due to her eagerness to attend her sister’s wedding, she agreed to the treatment but without the freewill to make the consent to it. As a human, everyone have their own rights to decide what they want to do with their life (Crisp & Taylor 2008, p. 379).
In the nursing profession, allowing patients to have autonomy is a vital component as it refers to the freedom of making decisions about everything in life, no matter whether it is good or bad for them, to the extent that regarding issues that involve one’s life (Burkhardt, MA & Nathaniel, AK 2008). It is clarified that you may not without the patient or their legal representative informed to treat patient, in addition to narrowly define only during emergencies (Garrett et al. 2010). It is the respect for a person no matter they are from which cultures, as all individuals are believed to be unique and valuable members of the society (Burkhardt, MA & Nathaniel, AK 2008). Thus no one have the authority to take the power of decisions making away from anybody. This negatively means a person, as precisely a person, without authority, should not have the power of another person no matter under what conditions there are at (Berglund, CA 2007). In other words, people do not lose their dignity, just because there are unconscious or sick, rather it should be equal or at least pass on to a surrogate for the incompetent. Based on the case study, Jill should allow Marie to exercise autonomy since she is capable of making her own choices about whether or not to accept medical treatments (Dresser, RS 2007, pp. 305-310). Although not all patients have the ability of utilizing autonomy (Dresser, RS 2007, pp. 305-310), in such cases even expertise, or people with a nursing license and any other professional person are not authorized to control the lives of others or constraints of the others (Garrett et al. 2010).
This is, then, brought about by the development of the medical version of the principle of autonomy: informed consent. Informed consent is indeed a process, not an independent event; but it is also the presence of communication and autonomous decision making. Informed consent is the medical and ethical concern for the patient’s owns the core (Manson, NC 2007, pp. 297-303). For the making of a successful informed consent the followings are to be met, 1) the patient or the appropriate surrogate need to understand the actual needs of the key issues or proposed treatment, and then, before giving treatment, the client must make an informed, voluntary, competent decision before proceeding on; 2) decisions are free willingly made whereby, without any influence from the health care professionals (Garrett et al. 2010); 3) the disclosure of information falls on responsibility of the nurses. As the expert health care professionals know how to describe the procedures, know its risks and benefits, because they are professionals. These risks should be explained to patients in order to facilitate decision making and also to decide whether to go for treatment or future management plans; 4) understanding the information given is crucial as it provides the complete recognition of the informed consent. Overall, if either of the above are not achieved, it represent there isn’t any patient-informed consent given and therefore no authorization of treatment should be allowed (Garrett et al. 2010). For Marie’s case even if her final decision was different to the suggested treatment proposed by the nurse or even different to the common paradigm of the general public, it does not prove that the patient is incompetent because each patient has their own value; and also some may prefer to suffer the pain from the disease rather than the pain from the treatment. Therefore, ethically health care providers must refrain from the temptation to intrude their values on others and carry out treatment against the patient’s will. As a nurse we have the obligation to respect the values and interests of the community (Dresden, E, McElmurry, BJ & McCreary, LL 2003). Otherwise nurses are considered as invading the patient’s body without any consent which is impermissible (Manson, NC 2007, pp. 297-303).
The above are the reasons for why autonomy is important in assisting consent making. But in contrast there are also critiques of consent. According to (Kerridge, I, Lowe, M & Stewart C 2009, p. 300-301) it was proposed that treatments regarding to health issues should less based on the respect of autonomy as it will reduce the importance of relationships during care, yet it should focus more on providing the best care for the patient. It was also argued that consent is not absolutely important to take when the patient’s life is at stake and it is ultimately inaccurate, comprehensive, and is culturally determined (Kerridge, I, Lowe, M & Stewart C 2009, p. 300-301).
But overall, it was proven that the patients who are being informed have a better communication and trust with the health care provider compared with those not being informed (Gold, M 2005).
Ethically as nurses we should be doing good (beneficence) to the patient and prevent doing harm (mal-beneficence). But it is impossible to do good in all situations, due to the nature of time whereby in a day only limited things can be performed, which eventually will result in the tendency of doing harm to patient. In other words, the principle of nonmaleficence restricts the principle of beneficence. In the clinical settings, we are bound to have performed some harm to patient, regardless how careful and cautious we are (Berglund, CA 2007, p. 104). It was argued by Kant 1996 & Mill 1998 (cited in Cullity 2007) that beneficence is an unacceptable responsibility, as nurses do have a duty to treat patient beneficently, but have discretion over when and towards whom the nurse is carrying out the beneficent actions to. This is the reason why the tension between the principles of beneficence and autonomy is frequently created.
Secondly, it was also mentioned that Marie was afraid of injections, thus a fear of needles may be a barrier to accessing good medical care (Wright et al. 2009, pp. 172-176). As a result, Jill has breached in a duty of care by lying to Marie that the injection is painless, where actually in fact it was a very painful injection and have to be administered slowly.
Another ethical principle identified was truth-telling (veracity) which is usually derived in large part from beneficence (Burkhardt, MA & Nathaniel, AK 2008, p. 20) and it is the main component which enhances the nurse-patient relationship. It is the aim of communicating in a truthful way with patient as therapeutic relationship is the fundamental notion in nursing context (Hodkinson, K 2008, pp. 248-256). It is due to this special bond between the nurse and the patient that the components of truth telling, compassion and communication are vital (Hodkinson, K 2008, pp. 248-256).
The reason for the importance of carrying out this principle is that, patients are not allowed to act on their own interest unless they are fully informed about the proposed treatment (Burkhardt, MA & Nathaniel, AK 2008, p. 19). Thus, even with the presence of negative information of the proposed treatment, nurses might tend to withhold the considerations of nonmaleficence, and informs patients about their life options and helps them to pursue the best path available (Berglund, CA 2007).
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However, even the benefit of being truthful is not obvious to the patient, yet as nurses we still have to respect that only the patient themselves can decide what is good or bad for them (Burkhardt, MA & Nathaniel, AK 2008, p. 19). The nurses in the hospital are always involved with the patient in disclosing information.
But however, on the other hand the disclosure of information may be complex. As stated in (Garrett et al. 2010), there are two important inter-related truths. The first one will be telling the truth but not as in telling the entire truth regarding the treatment (Garrett et al. 2010). Secondly, various truths may mean to be kept confidential (Garrett et al. 2010). As a result it is often difficult to decide what to tell and what not to. Although as a nurse we have the obligation to inform all information to the patient, but it those not cover all the truthfulness to the information (Garrett et al. 2010).
In the nursing context of ethics, truthfulness is being divided in to two meaning. First, is the action of not lying to the patient (Garrett et al. 2010). Secondly, is the need to communicate to those who have the right to know the truth (Garrett et al. 2010). It was argued that to be kept from information is not only insulting and paternalistic the patient but is actually causing further harm (Higgs, R 2007, pp. 333-337). The patient will feel more hurt if they found out that the treatment did not turned out to be the way the nurse explained to them. Ethically in the clinical setting the patients have the right to the truth regardless what, as the information is needed to allow them to make beneficial decision for themselves (Code of ethic statement 7). Even there isn’t the involvement of making an informed consent the patient still have the right to know the full information about the proposed treatment.
There is some concern being brought up regarding the uphold of veracity and being truthfulness with the requirement information in the health care settings, as it seems that professionals are not trained in this area (Berglund, CA 2007, p. 102). As patients, they have a very essential trust in the nurses, in such that they believe that the nurses are always doing the best for them (Berglund, CA 2007, p. 103).
However, on the other hand veracity is not an absolute obligation (Burkhardt, MA & Nathaniel, AK 2008, p. 19). It was mentioned that under two circumstances in which truth-telling may be ethically forbidden. Which in the first case, it is concerning the cases of minor patients, and secondly, is in the case where patient decides on what information they want to receive (Burkhardt, MA & Nathaniel, AK 2008, p. 19). As patient has the right to choose on how much information they want to receive, but veracity still holds, but needs to be explained but not imparting more information than the patient wants to know (Burkhardt, MA & Nathaniel, AK 2008, p. 19). Duties of veracity, although based on beneficence are also partly derived from respect for autonomy. This comes from the concept that patients have a right to information about their bodies and to truthful answers to their questions about their care.
Overall, Jill should have honestly discussed the proposed treatment and try to influence Marie the patient, wishes, as to provide with the best interest in care instead of threatening Marie. As a result, Marie might feel intimidate and Jill might lost his job as a nurse for the improper duty of care being carried out. As a nurse, Jill can offer other forms of treatments rather than by giving injection. Jill can also encourage Marie to accept the proposed treatment if there is no other alternative of treatments. The way of influencing a patient’s decision does not need to be considered harmful as long as the patient is eventually free to make his or her own decision and that decision is respected. Choices cannot be authentic unless they are informed.
In conclusion, the demonstration of respect for autonomy in patients is an ethical obligation in all clinical settings even if the patient’s own wishes may be acknowledged as unimportant by others in power (Sommerville, A & English, V 2007). As nurses we do not have the authority to take away this power from patient regardless under what circumstances. Informed consent is essential prior to care procedures that may threaten the autonomy of the patient if initiated without consent (Code of ethic statement 5). The goal of informed consent is to encourage meaningful decision-making (Aveyard, H 2001).On the other hand, for the treatment to be a beneficial one to the patient, it involves the respect for autonomy and the disclosure of full information regarding the proposed treatment (Code of ethics statement 7). And it is ethically not right for the nurse to lie or to invade the privacy of the patient just because it is subjected to medical procedures. Therefore, it is really important to maintain the both principles of autonomy and truth-telling in the clinical settings, no matter under what situations.
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