A. TOPIC This paper will discuss the theories of ethics as they are applied to quality healthcare and the preservation of the principles of confidentiality based on trust existing between patient and nurse. These ethical values are patterned from the Hippocratic oath which is used as the standard of care for physicians and were adopted by Florence Nightengale, founder of the modern nursing practice. The basic ethical values are commitment to patient, respect for human dignity, and patient’s right to privacy.
Ethics are defined as a system of moral principles, the study of values relating to human conduct, and a person’s judgment of what is right or wrong. The Nursing Code of Ethics requires that we, as nurses, provide quality health services to our patients while protecting their right to human dignity and privacy or confidentiality. Ethics are viewed as a way of deciphering between right and wrong and using moral reasoning to make decisions. Is it right to cheat on a test or falsify documents as long as no one knows?
Moral reasoning may be affected by our childhood experiences and training or religious beliefs. We use personal values to make decisions and solve dilemmas such as “what should I do if my baby is sick and needs me at home, but there is a shortage of staff at work and I’m needed there too”. Maternal values say that you should remain with your child, but work ethics say that you should go to work. We often are required to make a choice of two unfavorable alternatives. This presents a stressful situation for the nurse who usually must act promptly and be able to defend her decision if requested. B.
IMPORTANCE OF ETHICAL THEORY AND EXAMPLES -The two types of ethical theories used most often in solving ethical dilemmas are utilitarianism and deontology. Using the system of utilitarianism, also called situation ethics, the nurse will make decisions according to the situation and determine if her decision will create greater happiness for more people than any other alternative. Often she will make comparisons of risks to benefits in any given case. This could probably be successfully used in the case of a patient who had several treatment alternatives and one or more had greater risks but more benefits.
This would not be beneficial in the instant case study because the patient does not desire any treatments and only wants privacy and confidentiality. Therefore, unless the nurse could discuss with her the benefits of treatment and have her recognize the benefits of discussing the treatment plans with her husband, this decision making process would not be effective. The theory of deontology is a system of decision making based on moral rules and unchanging principles. It is based on duty and obligation and does not change according to the situation but remains steadfast in its emphasis on moral obligation to patients.
Other theories of ethics used in nursing practice are consequentialism, ethics of care, and virtue ethics. In consequentialism, we make moral judgments according to the outcome or consequences and believe that it is morally right if it has a favorable outcome. In ethics of care, we consider the importance of caring to build good relationships and friendships. Virtue ethics promotes the character of the nurse and says that nurses should be truthful and honest in their relationship with patients. The basic principles and concepts of medical ethics are autonomy, beneficence, nonmaleficense, justice, fidelity, veracity and confidentiality.
The principle of autonomy means respecting the individual’s right to make her own decision. The patient has the right to make her own decision even though the medical staff may disagree. Autonomy is acceptable except when the patient has a contagious disease and treatment is required by law. In the present case study, the patient is seeking autonomy in making her own decision about her refusal of treatment and seeks privacy and confidentiality in her decision not to inform her family of her illness and the necessary treatment despite cultural beliefs.
Beneficence is derived from the word beneficial and means that the care provider should be kind and helpful or beneficial to the patient. At times, there is a conflict about what provides the most benefit. The principle of beneficence raises issues between the patient and the nurse or the patient and the health care facility. At times, nurses may want to do what they believe is good for the patient and forget about the patient’s rights to choose. The ethical issue here is whether or not it is right for nurses to ignore the patient’s independence and impose that which they believe is good for the patient (Ludwick and Silva, 1999).
In the case at hand, if the nurse respects the right of the patient’s confidentiality knowing that lack of treatment will likely cause pain, suffering and death, is she doing a good deed for the patient? Is the fact that she is respecting the wishes of the patient and protecting her right to privacy doing what is good for the patient? Or should she recommend what she thinks is for the good of the patient forgetting about the patient’s right to choose? The principle of nonmaleficence means that the patient should not be harmed and gives the patient a right to be protected by the nurse.
Harm to the patient may be physical or emotional. The nurse can harm the patient by refusing to answer her call which could cause emotional distress to the patient or physical harm in the event the patient fell while trying to get out of bed without assistance because the call was not answered. Since such harm may either be deliberate or accidental, it is important that care is taken to prevent such harms by ensuring the reliability of the communication system and responding to calls as soon as possible. The resulting dilemma is how do we determine what is best.
While maintaining the privacy of the patient in the present case study is beneficial to her emotionally, it will physically cause harm and destruction to her body and will be shocking to her husband because he is not aware of her illness. Justice means that we must provide equal access to healthcare for all people with no discrimination; and fidelity says we are faithful to commitments and promises. In the instant case study, we have provided the access to healthcare without regard to cultural differences and have made a promise of confidentiality to the patient.
Veracity is simply being truthful to the patient and oneself in order to promote trust and confidence. At times, healthcare providers will use benevolent deception at the request of families because they believe that the bad news will be too devastating for the patient to accept. Confidentiality is the trust which is established between patient and nurse for the protection of the patient’s privacy. C. CONFIDENTIALITY – Maintaining confidentiality shows respect for the patient and encourages the patient to be open and honest with nurses and other healthcare personnel about her private life and anything that might affect her illness.
It provides her with assurance that her medical information may not make her subject to employment discrimination. It enables the patient to maintain self-control and privacy in her life. In the present case study, the patient has never been able to have any privacy and has been controlled by others all of her life. She may believe that this is her one opportunity to exercise her own rights to privacy. REASONABLE LIMITS -In 2003, the federal government issued health privacy regulations, known as HIPPA regulations, as mandated by the 1996 Health Insurance Portability Act.
This was intended to provide patients with privacy of their medical records; however, the privacy and confidentiality is subject to reasonable limitations inasmuch as health insurance companies and their employees have access to all medical records of a patient. Computerized medical records are available throughout the healthcare setting and fax and e-mail provide an opportunity for the patient confidentiality to be broken. Also, nurses and other health care staff may often find it necessary to discuss a patient in hallways, at desks or in elevators and something could be overheard by visitors or other patients.
There are exceptions to privacy rights of the patient for their own protection and these include records relating to abuse of children and elders as well as domestic abuse. Also, third parties are required to be notified in the event of criminally inflicted injuries, infectious diseases including aids, and threats of violence or harm to others. The complete record of the patient is not necessary under these circumstances; therefore, only the essential information is released to authorities or third parties.
The healthcare staff assumes that relatives may be notified about the patient’s condition unless the patient requests that such information be withheld. An advance directive would be useful to the patient in the present case study so that she could make her wishes known regarding her treatment thus avoiding unwanted treatment in the event she becomes unable to communicate her wishes. RATIONALE FOR KEEPING -In the present case study, the nurse should ensure that all treatment options are fully explained to and understood by the patient.
She should discuss with her the cultural differences which exist and that in western civilization, the patient is entitled to privacy and independence in choosing her own treatment or refusing treatment if she so desires. It appears that the patient realizes that she has the right of privacy as a patient insofar as the health care facility is concerned, but if her husband is made aware of her illness, he will exercise his right as the cultural head of the family to take over her rights as a patient and may attempt to force her to receive treatments.
The nurse has the responsibility to keep the patient fully informed so that she understands the nature, extent and general prognosis of her medical condition. She has the duty to protect the privacy of the patient if the patient so requests after being made aware of all of her options. RATIONALE FOR BREAKING -The rationale for breaking the confidentiality is that the nurse knows the patient will suffer and probably die from her illness and at some point will be unable to care for herself, at which time the husband will learn of the illness and the facility’s failure to notify him.
The nurse may believe that the patient’s life could be saved and will feel guilty about not making sure that the patient received the necessary treatment even at the expense of breaking the fidelity and trust bond with the patient. D. (conflicting principles autonomy and do no harm) A culturally sensitive health care system is one that is accessible as well as is respectful of the beliefs, attitudes and cultural lifestyles of its patients. Nursing values in the USA emphasize self-reliance and autonomy as the rights of any competent patient.
Competing moral choices, as in the instant case of family versus individual, present ethical conflicts. Nurses should be able to provide culturally appropriate care of patients by seeking cultural awareness, knowledge, understanding and skills necessary to effectively serve the ever-increasing culturally diverse population in America. The nurse should possess some understanding of the meanings of health and illness as interpreted by varying populations.
In the present case study, the male is the dominant figure and his mother is next in line; therefore, according to the cultural belief, the patient would have no right to make decisions for herself. On the one hand, the nurse owes confidentiality and privacy to the patient, and on the other, she has the duty to do what is good for the patient and causes her no harm. The patient apparently is competent and understands the nature of her illness and the consequences resulting from refusal of treatment. The patient also apparently thinks this decision is best for her.
As the controlling nurse, I would honor the patient’s right, after fully explaining to her the expected prognosis and what to expect from treatment or lack of treatment, and would believe that if she competently requests privacy and confidentiality, it is good that her wishes be honored. E. influence on culture – compare family and nurse values – intervention Because of the increasing population of immigrants in the US, cultural values, beliefs and traditions are having a greater impact on nursing care and decisions.
The values of the Z family differ from those of the nurse and doctor in the belief that the husband is head of the family, the husband’s mother is next in line, and the wife or patient has no individual rights or control in her personal life. The nurse and doctor practice the theory of autonomy wherein the patient has the independent right and control over her own body. She has the right to make her own decisions and is entitled to confidentiality and privacy regarding her medical condition. Intervention) The nurse, when faced with this dilemma, after carefully assessing the options, may counsel with the patient ensuring that she is fully aware of her illness and the probable prognosis with treatment and the lack of treatment. She may offer to discuss the patient’s options with family members with the consent of the patient. She may refer the patient to a counselor if the patient desires to discuss her condition or get another opinion. She should collaborate with other staff members to get ideas, opinions and suggested solutions.
If all else fails, the nurse should intervene on the patient’s behalf to protect her rights to privacy, confidentiality and autonomy. F. Decision making models: The steps involved in the process of making a decision are obtaining all of the pertinent facts and information necessary; determining the nature of the conflicts; determining which ethical principles are involved; seeking alternative solutions or remedies and determining what, if any, ethical violations appear in the alternative solutions; making a choice and preparing to defend the choice; and ending he process by following through with what is determined to be the best decision. In making her decision, the nurse makes a complete assessment of the patient’s illness, her attitude toward treatment, her attitude toward the family’s cultural beliefs, and her rights to confidentiality. She assesses the existing conflicts; the patient wants privacy; the family wants access to her medical records and believes they are entitled to this information based on cultural beliefs.
The principle of autonomy is involved because the patient has the right to act independently and is entitled to privacy and protection of her rights. Under the principle of beneficence, the nurse must do what is good for the patient and all concerned, and under nonmaleficence, she must do no harm. The nurse must decide whether breaking the confidentiality of the patient will do her more harm emotionally than to let the patient decide her own course of treatment, or lack of treatment.
The nurse’s primary obligation is to the patient; therefore, if she has fully educated the patient about her condition, her treatment options, and what will likely occur with no treatment, she should make a decision to protect the patient’s right to confidentiality. Upon making this decision, the nurse should be prepared to defend her choice, both legally and morally, and follow through with her solution as being fair, just and for the good of the patient.
CONCLUSION – In conclusion, the apn should maintain open lines of communication with her patients so that they may educate each other about cultural values and practices. She should ascertain that the patient understands the treatments she needs for her illness and the consequences of refusing treatment. She should advise her patient that in all reasonable probability her condition will deteriorate to a status in which she will be unable to care for herself and at that time her husband will probably take charge.
She should have her execute an advance medical directive so that her wishes with regard to treatment will be honored. In western civilization, a patient is entitled to the standard of care available in the area where she chooses to be treated; therefore, in the present case study, the patient is subject to the regulations of the health care facility, including her privacy and confidentiality privileges, irrespective of cultural differences.
If patient exercises her right to refuse treatment and medical staff disagrees, they have right to terminate the relationship with the patient but do not have right to enforce treatment. The nurse has the duty to explain any procedure and its probable results to a patient and to obtain consent for the procedure if the patient desires to have the procedure. In the present case study, cultural values say that the patient has no individual right to give consent, but western medicine says that she does.
Patients have the sole right to consent to or refuse medical treatment unless they lack the physical or mental capacity to do so, are unable to communicate for any reason as in comatose patients, are unable to understand treatment, or are minors. The patient may exclude any person or persons from participating in her care. Therefore, the patient’s privacy rights should be upheld by the nurse. References: Ethics In Nursing Practice Rumbald, Graham 1999
Nursing and Human Rights McHale, Jean Vanessa Gallagher, Ann 2003 Nursing and the Law, Staunton, Patricia J. Chiarella, Mary 2003 Legal Issues in Nursing Guido GW 1997 ANA NURSING CODE OF ETHICS Chitty and Black 2005 Encyclopedia of Nursing Practice Ludwick and Silva 1999 Journal of Law, medicine and ethics “Advanced Practice Nursing” Mariah Snyder, Michaelene Mirr 1999 “Ethics and Laws In Nursing” Kathleen Fenner 1980 “Conceptual Bases of Professionnal Nursing” Susan Leddy, J. Mae Pepper 1985 The Online Journal of Issues in Nursing