The aim of this essay is to discuss an ethical issue encountered whilst on placement. The discussion will focus on the influence of the key ethics theories of deontology and utilitarianism, ethics principles of autonomy, beneficence, non-maleficence and justice on decision-making in practice. It will consider the patients’ and staffs’ values and beliefs, legislation and professional practice. Confidentiality will be respected by using a pseudonym, Carol, in accordance with the Nursing and Midwifery Council [NMC] (2008) guidelines on confidentiality.
Carol, a 56 year old lady, was going through the menopause and was admitted to the gynaecology ward in hospital in the north west of England with symptoms of extreme lower abdominal pain and problems with urination. Following investigations she was diagnosed with a uterine prolapse which was causing involuntary urine loss and retention, and constipation. A clear explanation of the condition was given by the consultant who recommended that she undergo a hysterectomy to which she agreed because she was in severe pain.
While reading the informed consent papers before theatre, Carol made an explicit request that she should not be transfused with blood or blood products even in the case of extensive blood loss following surgery. Her reasons for this were that she belonged to a group of Jehovah’s witnesses, and it was simply against her beliefs. Ethics can be defined as the philosophical study of the moral value of human conduct and of the rules and principles that should govern it.
It is the code of behaviour considered correct especially that of a particular group, individual or profession (Orme-Smith & Spicer, 2001). The ethics theories of utilitarianism and deontology are most prominent in health care. Utilitarianism, which can be defined as ‘doing the morally correct event in the act of good’ (Winifred Tadd, 1988,) focuses on the consequences of actions, choosing those that do least harm. Linking this in with Carol’s case, if her hysterectomy was to go wrong and result in significant plasma volume loss, a decision would have to be made in her best interests.
If she were to be transfused her life could be saved but her future happiness as a practicing Jehovah’s Witness would be adversely affected. However, legally and ethically, Carol is assumed to be able to make decisions regarding her own body which should be respected. The NMC (2008) states if this was to result in a deterioration of health, or even death, in terms of ethics, it is simply not permitted to go against a patient wishes, whatever the cost. As health care professionals, we have a duty of care which we must pursue at all times.
Deontology, another ethics theory, focuses on the rightness or wrongness of intentions or motives behind action such as respect for rights, duties, or principles, as opposed to the rightness or wrongness of the consequences of those actions (Orme-Smith & Spicer, 2001). The deontological moral theory was proposed by Immanual Kant, where he puts great emphasis on to the duty of care. He also proposed that the principle of respecting autonomy was of most importance.
Carol has distinctly refused any blood products of any kind, so the duty of care given would be to do everything in power to solve the situation – except transfusion. Being a duty-based theory, deontology would require health care professionals to follow any rules, regulations, protocols or procedures laid down by the National Health Service and trust regardless of whether this was what the patient wanted. It can be seen that neither theory respects or works for the patients’ best outcome so a mixture of the two will normally be used to aid decision-making (Butts, 2005).
To translate the theories into practice, Beauchamp and Childress (2001) suggest that an ethics theories framework which includes autonomy, beneficence, non-maleficence and justice is helpful. Autonomy concentrates on self-directing freedom and moral independence. It is the right for patients to make their own decisions and for health care professionals to respect these at all times, whether they consider it to be the right choice for her or not (Kenworthy, 2002). Carol is an able-minded, 56 year old lady, who has been involved in the Jehovah’s Witness beliefs and values for a number of years.
She is capable of making such a decision after being made completely aware of the situation, including the pros and cons of her decision. Non-maleficence is the obligation to do no harm. Beneficence, simply means to do good, and is having the quality to be kind and considerate. Upon looking at these theories as a whole, there is no doubt about a conflict between these principles. Many moral problems faced by nurses stem from conflicts between obligations generated by the principle of respect for autonomy, against obligations generated by the principles of non maleficence and beneficence.
Treating a patient against their specific wishes applies to carols case. Autonomy can sometimes not be respected, with certain constraints such as the urge to act beneficently. In Carol’s case, this would be to transfuse if there was no other solution during her surgery/ aftercare, and it would be for the good of Carol, and acting in a way as to not harm her further (non maleficence). The nurse’s role is to assist the patient in making informed and appropriate decisions, in accordance to their own values or lifestyles (Chadwick & Tadd, 1992).
This means that morally no blood transfusion should take place as it is the patient’s decision that counts and should be respected. All medical interventions, whether diagnostic, therapeutic or for research – have the potential to violate patient autonomy. (Patient centred ethics, 2006). It is always for the patients’ best interests, and in Carol’s case she has put her religion before her potential life threatening surgery. This is still her choice, and no doctor or nurse should influence her decision in this. There is always going to be a potential clash.
Another important patient-centred ethical theory is Paternalism. Paternalism is a denial of autonomy, and a substitution of an individual’s judgements or action for their own good (David Jeffrey, 2006). None medical aspects to a persons life has more impact and significance to the patient then the illness/procedure at hand. Carol’s religion pays a big part in her life and everything surrounding it, i. e. lifestyle, family, and Doctors have limited qualifications to enable them to sum up the harms and benefits which acting in beneficence can cause.
The consequences of Carol receiving blood products of any kind against her will, would lead to her becoming shunned by her religion, something that obviously is top priority and could ruin her life, destroy her morals and everything she believed in. The refusal of a lifesaving blood transfusion by a competent adult Jehovah’s Witness, resulting in the death of a patient whose life could have been saved is an example of a true ethical dilemma. If Jehovah’s Witness patients are forced to accept a blood transfusion that is contrary to their beliefs, their autonomy as patients is clearly dishonored.
If patients die as a result of refusing this therapy, there is a sense that “harm” has been done and that a medical “benefit,” commonly available to others, was not available for these patients (David Jeffrey, 2006). Justice, another crucial ethics principle, where the underlining obligation is to respect the fact that everyone has the right to health care, no matter what their beliefs or values, gender, sexual orientation or race. This is an ethical framework that focuses simply on an individual’s rights risks being unfair to others, as issues of autonomy may cash with principles of justice (Verena Tschudin, 1992).
Alliteratively, justice can be understood in terms of fairness whereby a person’s claim to something is based upon a morally relevant property such as need (Fletcher, 1995). Informed consent is a vital factor without which the treatment could not ethically, legally or professionally take place. In current practice the emphasis has shifted from health professionals being obliged simply to disclose information to patients, to ensuring the quality of information exposed really enables the patient to make an autonomous decision (Fletcher, 1995).
The NMC (2008) states that: “You must ensure that you gain consent before you begin any treatment or care”. There are two main forms of consent – verbal/ action and informed written consent. These must be asked before any kind of care or treatment can take place. In Carol’s case, she had filled out a consent form, which listed all the limitations and health risks having her operation could entail. It was on this form that the possible need for blood transfusion occurred, and Carol expressed her belief issues with receiving this treatment if necessary.
Doctors generally feel that respect for the patient’s autonomy requires that this wish should be obeyed. They have sound legal reasons for this too, as to administer blood in the face of refusal by a patient may be unlawful and could lead to criminal and/or civil proceedings. Although Jehovah’s Witnesses cannot accept blood, they are open to other medical procedures (Garnet, 2000). Moving on ,in exercising authority, a health care professional is bound by the mental capabilities act (2005), which says that acting in good faith means acting with honesty, integrity, and due diligence.
They must look after the person who lacks the capabilities to act in good faith towards them. Informed adults who are capable of understanding news on their health have a legal right to refuse treatment, intending that refusal to take effect when they no longer have any capability of refusing treatment themselves. Advocacy is the pursuit of influencing outcomes — including public-policy and resource allocation decisions within political, economic, and social systems and institutions — that directly affect people’s current lives (Bob Gates, 1994).
Therefore, advocacy can be seen as a deliberate process of speaking out on issues of concern in order to exert some influence on behalf of ideas or persons. Based on this definition, Gates (2001) states that “ideologues of all persuasions advocate” to bring a change in people’s lives. However, advocacy has many interpretations depending on the issue at stake, which can be different from this initial value-neutral definition.