ethical and moral issues in healthcare by reason chivaka

ETHICAL AND MORAL ISSUES IN HEALTH CARE.

By Reason Chivaka: MBA, BSc, BA (Hons), HE Dip, Exe Dip, RGN, ACIPD, MCIM

Introduction

The need to adhere to the principles of consent and confidentiality can present

challenges to health care professionals. These challenges vary from professional,

moral, ethical and legal challenges and at times they present dilemmas that are

difficult to resolve.

A good example is that of, Mr P a 65 years old man who is admitted into hospital for

planned surgical procedure. He lives alone after having lost his wife five years ago

and his only daughter M lives abroad. Since his admission, his daughter phones

everyday enquiring about his condition and also requesting to speak to the patient

who unfortunately could not speak to her because of his condition.

Four days post operative, his condition started to deteriorate but he requested that

both medical staff and nursing staff should not tell his daughter about his worsening

condition. His main reason was that, his daughter was far away and he did not want

her to be worried and stressed, hence no information was given to his daughter as per

his request. However, when his condition deteriorated further and the medical staff

were considering was to take him back to theatre, staff in the ward queried whether it

was professionally and morally right to uphold the patient's request. The argument

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was that, as the only next of keen, the daughter should be told about the his father's

condition. Consequently the staff were no longer comfortable to persist telling his

daughter that, his condition was fine when in actual fact he was deteriorating. The

Registrar approached the patient about the issue but he was still adamant that his

daughter should not know. By the time he eventually agreed his condition had

worsened such that after theatre he ended up in up in higher dependence unit (HDU)

for three days before being transferred back to the ward.

When the daughter was finally told, she was shocked and when she saw him was

really distressed. Although the patient eventually recovered well and was discharged

after three weeks, the incident left health care staff feeling really bad.

Thoughts, Feelings and Concerns

During such incidences, health care staff particularly nurses feel very guilt about

withholding information from patient's next of keen. The main worry is whether

hiding information from the next of kin is morally, ethically and professionally right.

Whilst the patient's choices should be respected, the main question is what will the

next of kin think about health care professionals they eventually find out the patient's

real condition. Although it was understandable that in the case of Mr P, he did not

want his daughter to be stressed, health care professionals usually feel uncomfortable

and burdened by such incidences.

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Issues raised by the Incident and Impact on Practice and Professional

Development.

Whilst such incidences usually result in most health care professionals feeling

uncomfortable, burdened and guilty, they have significant effect on professional

practice. Mr P's case provides an insight into the challenges faced by health care

professionals everyday and the difficulties of decision making when dealing with

professional, moral, ethical and legal issues.

The incident raised some professional, moral and ethical issues regarding the patient's

right to consent, participation in decision making, confidentiality and need for the

health care professionals to be honesty and trustworthy. Patient's rights are composed

of a mixture of civil, legal and moral rights. Johnstone (2006) said that, the issue of

patient rights has received considerable attention such that, there has been significant

policies and laws regarding patient's rights. All these endeavours are meant to prevent

the violation of the rights of the patient and to ensure that their choices are properly

respected and protected. However it remains debatable as to what sort of rights can

patients meaningful and reasonably claim in certain contexts. Patient's rights vary

from the right receive informed consent, the right to participate in decision making,

the right to confidentiality and to be treated with respect. Burnard and Chapman

(2005) argued that, it is very difficult for health care professionals to make decisions

in cases where the patient's rights compete and conflict with the professional, ethical

and moral obligations of nursing staff. The major challenge in this incident was trying

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to balance the rights of the patient with his professional, ethical and moral and legal

obligations.

Theoretical Underpinnings

Professional Issues

Health care professionals, for example nurses are expected to work in accordance

with the strict standards of their professional conduct. In the UK, the NMC Code of

Professional Conduct governs the way nurses conduct themselves at work. The NCM

Code of Professional Conduct (2008) states that, nurses should respect their patients

and treat them with dignity, respect patient's confidentiality, collaborate with patient's

in their care and ensure that they gain consent before treatment. The idea is that, there

should be trust between the nurse and the patient. Patients should feel safe and should

trust the nurse with their health and well being. Other important documents that have

an impact on professional issues are the code of ethics and competency.

The codes make it abundantly clear that, when practising, nurses must uphold the

highest standard of ethics and should be role models of excellent behaviour

(Johnstone:2006). The vulnerability of the patient's under the care of nurses is one of

the fundamental reasons behind this level of expectation. The vulnerability of the

patient's should be minimised by ensuring that nurses conform to the highest ethical

and professional standards. Benjamin and Curtis (1992) defines code of professional

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standards and ethics as a document that stipulates professional and moral rules or

expectations whose purpose is to guide professional conduct. Whilst the code of

professional conduct is meant to guide nurses at work, in practice, there are many

challenges that are faced by nurses. For example the code of professional conduct

states that, nurses must maintain patient's confidentiality, respect patients, preferences

and decisions, yet when faced with situations where a vulnerable patient is being

abused by carers or relatives, it is difficult to do so.

The NMC Code of Conduct (2008) states that, nurses must be advocates for their

patients. In practice the issues of being patient advocates causes both professional and

moral dilemmas. When dealing with situations where a vulnerable patient is being

abused by carers or relatives, trying to uphold the interest of the patient, means those

of the carers are violated. By not telling the next of kin the truth as requested by the

patient means that, the nurse will be upholding the patient's right to information

sharing and decision making but may also be violating their own code of professional

conduct which states that, nurses should conduct themselves in an honesty and

truthful manner. In such a situation, how will nurses justify their conduct of not

telling the carers or relatives the truth.

These examples show that, nurses are always faced with professionals, ethical and

moral issues and dilemmas that impact on decision making. The question is should

health care professional be guided by their professional code of conduct only or they

should also consider moral issues.

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Moral Issues

The nature of the work nurses do, present challenges in terms of decision making

when confronted with problems that causes moral dilemmas. The main questions that

most nurses will be asking themselves are, how to deal with a given situation, what is

the best course of action, how to know the whether the decision is morally right and

whether the behaviour is ethically correct.

The answers to the above questions are not straight forward as the way one would

answer them is influenced by one's beliefs, values, life experience, professional

knowledge and experience (Johnstone:2006). However, there is an argument that

such situations requires a systematic approach, experience and consideration should

be given to all the issues at stake in order to find a way of how best to resolve them.

According to Little (2001), the problem with moral issues is that there is no universal

consensus on what should be considered right or wrong and moral beliefs can be

misguided resulting in mistaken moral judgements. The best way to deal with moral

decisions is to provide good reasons for decision and actions taken.

Beauchamp and Childress (2001) argued that, justification of moral decisions should

be supported by strong moral reasons. Various theories guide professionals in dealing

with moral problems. Moral theories present the means for assessing the moral values

of actions and they help nurses to deal with incidents that present moral dilemmas

(Melia:2004). The major ethical theories that are used to deal with moral challenges

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are deontological which states that, regardless of the results, duty is the basis of all

moral actions (Fry and Johnstone:2008). On the contrary, teleology states that, the

results should be the only basis for judging the actions of moral actions

(Rumbold:2005). The principle of autonomy emphasises the patient's ability to make

independent decision, whilst that of beneficence states that, nurses should work for

the benefit of their patients ( Thompson et al:2003). Whilst these and other theories

differ on how to deal with moral dilemmas, they agree on the fact that the

competence of individuals in making their choices is vital.

Moral theories are important because they help people to describe, understand their

world and devise moral standards that provides them with frameworks in determining

what is acceptable actions and what is not. Burnard and Chapman (2005) argued that

evaluation of moral judgements, decisions and reflection is only possible with moral

theoretical underpinnings. In practice moral theories help nurses to deal with

situations that present moral dilemmas that makes decision making very difficult.

Withholding information to carers and relatives at the request of the patient, presents

moral dilemmas to nurses as it is morally wrong to tell relatives that the patient is fine

when knowing very well that the condition is deteriorating. Whilst it is in accordance

with the NMC Professional code of Conduct (2008) to respect patient right to

decision making and information sharing, it is morally wrong not to tell the truth to

family members especially those who may be abroad and are not able to visit the

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patient. The morality of any decision made is questioned on the basis of its moral

worthiness and consequences and how that affected the people involved.

Legal Issues

Legal issues affect nurses in their everyday work as evidenced by the ever increasing

ligations against the National Health Services (NHS) due to clinical errors, wrong

decisions and other issues. Aiken (2009) said, law is the foundation of statutes, rules

and regulations that govern people, health and safety and welfares as well as

relationships and behaviour and interactions with society.

The law is important in nursing because what is considered professionally, morally or

ethically right may be interpreted as illegal by the law. According to Fry and

Johnstone (2008), what may be ethically right may be legally incorrect and vice

versa. The case of euthanasia is a classic example of how the law clashes with

professional and moral values. Whilst the argument is that, it is morally right to help

people who are in persistent and severe pain who decide to die, the law states that it

is illegal to do so and such actions are considered as murder (Pozgar et al: 2009).

Therefore the question is, do patients have the right to make autonomous decisions

and are nurses able to exercise their advocacy roles without having to thinking about

the legal consequences?. The answers is that, the law is supreme in whatever we do

and nurses should abide by the law and should be very careful as the law is a different

guiding system to professional, moral and ethical guidelines.

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In nursing legally defensive decision making is the norm. Even though a nurse may

feel that it is professionally, morally and ethically right to do something, it is the legal

consideration that guides the action to be taken (Kluwer:2008). This means that, a

nurse may refuse to do something just because doing so is considered illegal, hence

such a decision is guided by legal rather than moral or clinical decision. It is therefore

vital to highlight that, most decisions taken by nurses are influenced by

considerations of legal consequences rather than clinical or moral consequences of

complying with the request of the patient. The challenge for nurses is how to deal

with dilemmas emanating from the conflict between professional, moral, ethical and

legal issues.

Discussion of Actions taken (Personal and Professional Values)

The first issue raised by this incident was the patient's right to make autonomous

decisions and the right make choices especially on information sharing. The other

issues were the patient's rights to consent, confidentiality and the need for nurses to

be honesty and trustworthy.

The NMC Code of Professional Conduct (2008) states that, nurses should respect and

uphold the patient's rights to make autonomous decisions and that the nurses must be

honesty and trustworthy. The patient in question was competent to make his own

decisions regarding his care hence health care professional were expected to respect

and uphold his decision as required by the professional code of conduct. Respecting

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and upholding the patient's decisions entailed not telling his daughter his actual

condition. According to Wallace (1991) confidentiality means not disclosing any

information relating to a patient except with their consent, when required by law or to

alleviate a serious threat to life and health. The principle of confidentiality has

historically been interpreted as an absolute principle, meaning that at times disclosure

of information is not permitted even if the outcome of doing so is good.

During an incident similar to this one, the actions of health care professionals are

guided by the principle of confidentiality. Consequently no information pertaining to

the patient's deteriorating condition will be given to the next of kin. Childress (2001)

argued that, the justification of the supremacy of the confidentiality principle in

health care practice is due to the need to preserve the trust between the health care

professional and the patient. Looking at this incident, it was clear that, the patient

relied on health care professionals to keep his condition confidential from the

daughter. An attempt to violate that trust by disclosing his condition without his

consent was going to destroy the trust and the relationship between the patient and

healthcare professionals. The principles of consent and confidentiality are

fundamental as they guide actions in health care professional- client relationship

(Pozgar et al: 2009). The other fundamental reason why these principles are

important is because they are recognised in law.

Health care professionals found themselves in a dilemma as whilst it is legally right

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to respect and uphold the patient's rights to consent and confidentiality, on the

contrary, there is a strong feeling that, it is morally and ethically wrong to hide

information pertaining to the patient condition to the next of kin. Withholding the

correct information to the next of kin just because the patient requested so, presents

professional, moral ethical and even legal dilemmas to health care professionals.

Pozgar et al (2009) said that, moral dilemmas arise when values, duties, rights and

consequences of an action conflict. The NMC Code of Professional Conduct (2008)

states that, nurses should uphold patient's rights to consent and confidentiality. It also

states that, nurses should be trustworthy and honesty, meaning that, they should tell

the truth. In incidences like this, it is difficult for health care professionals to

reconcile these two conflicting provisions of the code of professional conduct.

Withholding the information from the next of kin as requested by patients is right

because it means their rights to consent and confidentiality are respected and upheld.

On the contrary, persistently giving incorrect information tot the next of kin is a

violation of the professional code of conduct which states that, nurses should be

honesty, trustworthy and should always tell the truth. Most healthcare professionals

feel that doing is professionally, morally and ethically wrong. However, they also

feel that, violating the patient's rights to consent and confidentiality could have severe

legal consequences. On the contrary if something is to happen to the patient and then

next get to know the truth, healthcare professionals will end up being sued.

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Since the law is supreme, discussions among health care professionals is usually

centred on the legal consequences of not upholding the patient's rights to consent,

confidentiality and legal consequences of withholding information from the patient's

next of kin. In health care, decisions are made on the basis of what is required or

prohibited by the law (Johnstone:2006). The guiding principle in decision making by

health care professionals is based on doing actions that do not result in legal actions

and accompanying costs of failure to comply (Kluwer:2008). With this in mind most

healthcare professionals will resolve such dilemmas by discussing with the patient for

them to consent to the release of information regarding their conditions.

Conclusion

Problem solving is not easy for healthcare professionals because the rights of the

patients to consent, confidentiality and the legal consequences usually out weigh the

professional, moral and ethical issues. Violating patients right by releasing

information to the next of kin without their consent will usually destroy the trust

between patients and health care professionals. On the extreme end, violating these

rights could lead to legal action that could be costly. The NMC code of Professional

conduct (2008) makes it very clear that, failure to comply with the provisions of the

code could bring the fitness to practice of a nurse into question and endanger the

nurse's registration. Whilst feeling morally and ethically guilty the only way

healthcare professionals resolve such dilemmas is by persistently asking the patient to

reconsider their decisions.

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This is in consideration of the fact that, in such incidences, moral and ethical issues

are subordinate to legal and professional considerations. Kluwer (2008) argued that,

even though a nurse may feel that it is professionally, morally and ethically right to

do something, it is the legal consideration that guides the action to be taken. The truth

is that moral judgement, which involves being able to choose an option from among

choices is very difficult to exercise in nursing (Pozgar et al: 2009). However, whilst

moral and at times professional issues are subordinate to legal issues, they are

important as they help in deciding the course of action to take. Kopelman (1995)

advised that, when faced with a moral dilemma healthcare professionals should not

only rely on personal experience and preferences but to look elsewhere to strengthen

our moral choices and actions.

References

1.Aiken. T.D and Catalano. J.T (2009) Legal and Ethical Issues in Health

Occupations. 2 nd Edition . Missouri: Saunders Elsevier.

2.Beauchamp.T. and Childress.J. (2001) Principles of Biomedical Ethics. 5 th Edition.

New York: Oxford University Press.

3.Benjamin.M. and Curtis.J (1992) Ethics in Nursing. Oxford: Oxford Press.

4.Bulman.C. and Schutz. (2008) Reflective Practice in Nursing. 4 th Edition . West

Sussex:Blackwell Publishers.

5.Burnard.P. and Chapman.C. (2005) Professional and Ethical Issues in Nursing. 3rd

Edition. London: Bailliere Tindall.

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6.Fry.S. and Johnstone M.G. (2008) Ethics in Nursing Practice: A Guide to Ethical

Decision Making. Oxford: Blackwell Publishers.

7. Johns. C (2004) Becoming a Reflective Practitioner. 2 nd Edition . Oxford: Blackwell

Publishers.

8. Johnstone. M.J. (2006) Bioethics:A Nursing Perspective. 4 th Edition . Marrickville

NSW: Elsevier Australia.

9. Kopelman.L. (1995) Conceptual and Moral disputes about Futile and Useful

Treatments. Journal of Medicines and Philosophy, 20(2), pp 109-21.

10. Kluwer.W. (2008) The Evidence Based Nursing Guide to Legal and Professional

Issues: New York: Lippincott Williams and Wilkins.

11. Little. M. (2001) On Knowing Particularism and Moral Theory. Hastings Center

Report, 31(4), pp 32-40

12. Melia.K.M. (2004) Health Care Ethics: Lessons from Intensive Care. London:

Sage Publications.

13. Parker.D.L. (2006) Reflection and Critical Incident Analysis: Ethical and Moral

Implication of their Use within Nursing and Midwifery Education. Journal of

Advanced Nursing: Volume 22. Issue 6. Pages 1050- 1053. Blackwell Publishing.

14. Pozgar.D.G. Santuce.N.and Pinelle.J.W. (2009) Legal and Ethical Issues for

Health Professionals. 2 nd Edition . Boston: Jones and Bartlett Publishers.

15. Rumbold.G. (2005) Ethics in Nursing Practice. 3 rd Edition . London: Bailliere

Tindall.

16. The Nursing and Midwifery Council Code of Professional Conduct (2008)

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Standards for Conduct, Performance and Ethics. London: Publishing Department,

NMC.

17. Thompson.I.E. Melia.K.M. and Boyd.K.M. (2005) Nursing Ethics. 4 th Edition.

London: Churchill Livingstone.

18. Tripp. D. (2001) Critical Incident in Teaching: Developing Professional

Judgement. New York: Routledge Publishers.

19. Wallace. M. (1991) Health Care and the Law: A Guide for Nurses. North Ryde:

The Law Book Company.

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