The nursing practice is guided by strict codes of ethics which promote beneficence and protect the patient. These standards, often legally supported, provide a framework which the nurses use to provide ethical and professional care. However, the complexities of the healthcare system and patient demands may create morally ambiguous situations forcing nurse practitioners to consider their options.
The dilemma consists of a 45-year-old female patient with third stage of ovarian cancer wanting to discontinue treatment. However, the patient has developmental and mental issues since birth, although she is able to function independently. No immediate family members are present to assume guardianship. This situation would apply to a nurse practitioner treating the woman. Therefore, the ethical conundrum consists of the decision whether to abate life-sustaining cancer treatment in a patient that may potentially be nonautonomous.
The principle of beneficence, or the pledge to not harm the patient, is violated if treatment stops. However, if the treatment continues, the principle of patient autonomy is overlooked. Patient autonomy states that the patient has the right to participate in the clinical decision-making process and make the final judgment on whether to receive treatment (Reach, 2013). The legal principle which may be challenged is informed consent, protecting patients from battery in the form of undesired medical interventions and supporting the right to self-determination and autonomy (Hall, Prochazka, & Fink, 2012).
As a nurse practitioner, there are limited options to a decision that could be made. However, one can utilize the resources of the healthcare system for support. First, a conversation should held with the patient, attempting to understand the reasoning behind the decision and providing evidence-based information to support the argument that treatment can be beneficial at this stage of the of the disease.
Since the patient is identified as having an intellectual disability without immediate guardians or caretakers to oversee her healthcare, it may be possible for the institution to legally establish guardianship over the patient if it is determined that a patient is unable to make self-interested decisions about healthcare. It overrides a patient’s desires and consent to medical treatment (National Guardianship Association, n.d.). This is done through the hospital’s legal counsel and social worker that seek a court order. It inherently addresses the legal and ethical dilemmas that arise in this scenario by seeking a legal alternative to providing necessary care to a patient who may be mentally unstable.
Legal Principles and Laws
Most commonly, ethical standards are interconnected with legal principles which seek to protect individual patient rights. Autonomy is an enforceable legal right, and patient decisions should be respected since they are made based on individual ethical beliefs and situations. One of the core legal principles of patient autonomy is the right to refuse treatment which is recognized by both national and international courts unless there is clear evidence that the patient has no decision-making capacity (HospiceFriendly Hospitals, 2013).
Patient autonomy and informed consent can be challenging to address from both legal and public perspectives. High profile cases have dominated the news cycle about the issue. A most recent one, an 18-year-old female was held against her will at a hospital after undergoing major surgery. However, after disagreements with the girl’s parents, the hospital staff began to place limitations on visitations as well as pressure certain medical decisions while the patient and her family wanted to transfer.
The hospital sought to assume guardianship rights. When the young woman demonstratively left the hospital, law enforcement was involved based on charges of kidnapping. In turn, the patient is seeking to sue the hospital for violating her patient autonomy rights (Cohen & Bonfield, 2018). Conclusively, legal experts argue that incidents such as this demonstrate that guardianship and informed consent are aspects of the medical law that should be approached with caution.
Ethical reasoning is focused on the considerations of philosophy and ethics. It encompasses morality, responsibility, and virtues of character. Ethical reasoning is based on deliberation and justification of actions based on motivations and consequences. Meanwhile, legal reasoning is based on the context of law and jurisdiction, based on legislation, policy, and court decisions. Therefore, legal arguments are based on the interpretation of the law and are limited to precedents set forth by previous cases (Rentmeester, 2006).
In the healthcare context, a patient is inherently vulnerable and dependent on the healthcare professional. That is the reason why patient autonomy was established as an ethical and legal principle. However, to preserve control, a patient may choose to reserve to drastic measures in order to feel in control and practice independence, even at the cost of self-harm (Lindberg, Fagerström, Sivberg, & Willman, 2014).
Healthcare professionals are faced with a daunting task of assessing whether an individual has the capacity to consent to treatment. This is an ethically ambiguous concept since it must balance the respect of a patient’s right to autonomous decision-making with their decisional capacity. Nevertheless, a treatment cannot be provided unless a patient or legal guardian has given valid and informed consent. However, active consideration of decision-making capacity becomes relevant when a patient disagrees with a reasonable treatment option because of individual values (Palmer & Harmell, 2016).
In other words, the risk-benefit considerations weight towards the provision of treatment. While decisional capacity is associated with severe mental disorders, it is significantly more widespread, affecting approximately 26% of medical inpatients (Palmer & Harmell, 2016).
Currently, there are no pragmatic or quantitative methods to evaluate decision-making capacity. Therefore, to address the ethical concerns of treatment while adhering to the rule of law, a health professional would be correct by seeking an independent counsel in the form of a court ruling. A judge can declare legal guardianship based on the testimony from health professionals, mental health experts, and even the patient herself. The ethical concept is fulfilled by a nurse seeking a method to deliver treatment (beneficence) without directly disrespecting patient autonomy, in both legal or ethical terms. Since a due process of law is followed to determine mental capacity, the patient’s autonomy rights are not violated.
It is not uncommon for nurses to navigate moral distress when faced with challenging ethical dilemmas. Nurses working with critically ill patients are more likely to experience acute stress and distraught from the anguish of such situations. Recommendations to deal with such issues begins with ensuring that professional standards, nursing organizations, and hospital boards have straightforward procedures and a support network to empower nurses in such cases, ensuring that the nurse is protected in terms of professional ethics and the law. Furthermore, a nurse should communicate with their team to build collegial support and enable early recognition of any potential dilemmas. Finally, nurses are encouraged to seek the support of social work services or a religious chaplain to obtain guidance in an ethically distressing scenario (Matey, 2016).
Legally and ethically, patient autonomy and informed consent remain the core principle of providing healthcare treatment. Depending on the patient’s mental health status, a nurse practitioner can seek a court-ordered guardianship of the patient by the institution. However, legal precedent shows that such rulings are rare and there must be concrete evidence of the patient displaying lack of decision-making capacity or a direct family guardian who can assist with such duties. In the contexts of this scenario, it would be unethical to force any treatment upon the patient without their agreement unless decision-making capacity is compromised.
Cohen, E., & Bonifield, J. (2018). Escape from the Mayo Clinic: Teen accuses world-famous hospital of ‘medical kidnapping’. CNN. Web.
Hall, D. E., Prochazka, A. V., & Fink, A. S. (2012). Informed consent for clinical treatment. Canadian Medical Association Journal,184(5), 533-540. Web.
Lindberg, C., Fagerström, C., Sivberg, B., & Willman, A. (2014). Concept analysis: Patient autonomy in a caring context. Journal of Advanced Nursing,70(10), 2208-2221. Web.
Matey, L. (2016). Navigating moral distress in the face of ethical dilemmas. Web.
National Guardianship Association. (n.d.). What is guardianship? Web.
Reach, G. (2013). Patient autonomy in chronic care: Solving a paradox. Patient Preference and Adherence, 8, 15-24. Web.
Rentmeester, C. A. (2006). What’s legal? What’s moral? What’s the difference? A guide for teaching residents. The American Journal of Bioethics, 6(4), 31-33. Web.