Chapter 6: Ethical dilemmas

Learning objectives

By the end of this chapter you should be able to:

- Identify common ethical dilemmas in nursing practice.

- Understand how patients and healthcare professionals interact to make decisions.

- Demonstrate an ability to weigh up evidence when serving the best interests of the patient.

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Common ethical dilemmas

The main ethical principles of nursing are intended to guide decision-making to ensure the best outcomes for patients, while respecting patient rights. These include the right to autonomy, dignity, respect, justice and equality. It is also important to involve patients in the decision-making process as much as possible. The following sections of this chapter will consider key situations where ethical treatment is complicated by conflicting rights and nursing obligations of care.

Patient autonomy versus nursing expertise

One of the most commonly encountered ethical dilemmas in practice relates to differences in the way the nurse and patient may view a clinical decision. Nurses have skills and knowledge of disease and treatment; however, patients have the right to autonomy and have the final say in their own treatment. When opinions oppose, this can create a challenging clinical situation.

For example, patients may wish to discharge early from the hospital setting. This may be against the wishes of medical and nursing staff, but the patient has a right to make this decision provided they are aware of the risks and have the freedom to make a decision. Unless the patient is at serious risk of harm, nurses should respect their wishes. This should be clearly documented in the notes, including necessary discussions with the patient prior to discharge. Holding the patient against their will would violate their autonomy and freedom - even where knowledge and expertise suggest that the patient should remain in hospital.

The nurse should serve as a patient’s advocate; your role is not to decide for the patient, but to provide them with all of the necessary information to guide their decision. Patient autonomy should always be valued - even when patients make ‘unwise’ decisions. However, you should ensure that the risks are clear.

Refusal of life-saving treatment

Patients may refuse to receive treatment that will save their life. In this situation, nursing staff and medical staff may have a clear opinion of the need to intervene, but the patient disagrees with the course of action. This may include life-saving surgery, medication use, or other interventions that will directly prevent serious harm to the patient.

In practice, nurses should determine the capacity of the patient, examine their reasons for refusal, and determine the extent to which ethical care can be delivered. Capacity should be assessed, and it should be determined whether or not the patient is able to make this decision based on this assessment. If a patient does not have capacity, suitable approaches may be used to advocate for treatment. If a patient is found to have capacity and has made a clear decision to refuse care, then you should make sure that they are aware of the consequences of treatment refusal and that they are not being coerced by others. If the patient continues to refuse, it may be necessary in some cases to seek legal and professional advice.

Regardless, you cannot force treatment on a patient or provide them medication covertly. This would be unethical and can constitute an act of harm or assault, which may have severe legal and professional repercussions. You should always engage patients in an open discussion about treatment options and act ethically to prevent risk to your own professional status.

Parents’ rights to decide for their child

In the case of young children, parents have the right to determine the course of treatment and the right to refuse treatment on behalf of the child. However, nurses should consider the best interests of the patient, rather than the parents, and therefore discussions around care decisions need to be detailed and sensitive in nature.

For example, parents may refuse certain treatments or object to a prescribed treatment course. The parents may feel that alternative options are better or that further treatment or interventions may be too painful or distressing for the child. You should establish the reason why the parents’ opinion differs from medical advice. You should discuss the issue in a calm and sensitive manner, asking them about their concerns, ideas and expectations. Often, parents are stressed or anxious, and this could affect their judgement as to the best course of action for their child. However, provided parents have all of the relevant information, judgement cannot be assumed to be impaired unless they specifically lack capacity. Parents have the right to make decisions that differ from the judgements of nursing staff and medical staff.

However, nurses’ primary duty of care is to the patient. If you feel that the parents are making a decision that could negatively affect the health or wellbeing of a child, you need to act as a patient advocate. You should explain the situation carefully to the parents and the need for the intervention. Then, if the parents refuse, you may need to seek further professional or legal guidance on how to proceed. It is not acceptable to simply ignore the wishes of the parents; ideally their consent should be obtained before treatment. However, in exceptional circumstances, nurses may be legally able to intervene.

Circumstances where parents’ wishes need to be challenged are rare in practice. In general, discussing all of the options and facilitating informed decision-making is preferable to a more confrontational attitude. Both the child and parents should be encouraged to participate in the treatment course, while serving the best interests of the patient.

A child may be able to make their own care decisions or refuse certain forms of treatment. In the UK, once an individual is 16 years or older, they are legally responsible for their own care, and can provide consent for procedures or treatment. Children under the age of 16 can consent if they are reasonably able to understand and process the relevant information - as per the assessment of capacity. This is known as ‘Gillick competence,’ based on the legal case that informed this decision.

Situations where patients and the child disagree can be complex and almost certainly require legal input. In these instances, it is important to maintain clear communication between family members and to ensure that the full repercussions of decisions are understood by all involved.

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Honesty versus information

Nurses need to be able to meet the information needs of their patients. This may involve educating a patient on their condition or advising them on a therapy. The level of detail provided should be appropriate to the individual. However, this may be difficult. Nurses often have to balance the need for information with the potential negative consequences of too much information. This is consistent with the role of the nurse as an advocate for patients; tailoring care to the needs of the individual.

For instance, if a patient is extremely worried about a potential diagnosis or outcome of a test, the way you communicate risk or potential outcomes is important. If you provide extensive details of the risks, you may alarm the patient or cause undue anxiety. Conversely, withholding key risk information when achieving consent is bad practice, as the patient is not fully informed and thus cannot be expected to make a clear decision. In cases where patients may not desire all of the necessary information, or these details may cause anxiety or worry, the nurse should address the patient’s specific information needs. It is often not necessary to detail every risk with a procedure or medication, but the key risks should be communicated. You should consider how much information you should provide, as patients’ wishes will vary. However, it is unethical to be dishonest to a patient if they require information.

Another instance where honesty may be compromised in practice is when discussing sensitive issues with patients and family members. For example, a patient may request that their diagnosis or prognosis is withheld from family members. You should follow the wishes of the patient and withhold this information. If discussing the care plan with the family, this situation may prove challenging, as you cannot lie to the family, but you should respect the patient’s wishes. Therefore, you should make sure that the family are informed of all relevant details of care, while respecting the rights of the patient. When difficult conversations arise, it is often best to defer to the patient. Often, people need some time to come to terms with some diagnoses, so a patient approach is needed.

Breaking confidentiality

Patient confidentiality is a fundamental right and nurses should respect this at all times. However, this is not an absolute right and there may be occasions where breaking confidentiality may be necessary. You should carefully consider the legal and professional implications of breaking patient confidentiality when necessary. Consulting with colleagues or professional bodies may help you.

Examples include when the patient poses a serious or ‘real’ risk of harming themselves or others, when police officers require specific information on patients, and where a patient’s refusal of treatment may lead to others being exposed to a significant risk. In each of these circumstances, care should be taken to ensure that the patient has been fully informed of the reasons why confidentiality may be broken. For instance, if police contact you regarding a patient who is suspected of a crime, you are obligated to assist in their investigation. However, the information provided should be consistent with that requested by police. For example, if the police are enquiring about a patient who may have a broken arm, you would be at liberty to cooperate with the police, but do not need to provide details of the patient’s medical condition. The patient’s name and address should be provided, ideally with the patient’s consent.

Patients posing a risk to others, either through their mental state or refusal of therapy, is a challenging scenario. Patients may act aggressively or threateningly; you should consider how serious this threat is and whether the patient intends to harm another person directly. If the risk is considered serious, then the local authorities may be contacted and confidentiality broken, though this should ideally be done with the patient’s consent. Similarly, if a patient refuses treatment for an infectious condition that poses a risk to the general public, involvement of authorities or medical professionals may be justified. Nurses should be able to justify why confidentiality was broken.

The use of restrictive measures or patient detention

Patients may act aggressively or threateningly towards staff or others, or where patients may pose a risk of harm to themselves. It may be difficult to calm the patient down and the use of behavioural techniques may not prevent the patient from harming themselves or harming others. These situations arise in a mental health context in particular, where patients may have distorted perceptions of reality, including paranoia and delusions. When confronted, patients typically lack the capacity to make decisions. In these instances, you should consider the use of restrictive measures or patient detention under the Mental Health Act 2007.

As a nurse, you should only ever use powers of detention when they are absolutely necessary, to avoid misuse of power and compromising patient rights. Similarly, use of physical restraint, chemical restraint or restrictive practices may be considered unnecessary if used without proper justification. These should be last resorts and should be performed in accordance with local guidelines.

You should remember that when these measures have to be used, you are still serving the patient’s best interests. If you did not apply these measures, the patient may cause injury or may deteriorate. It is not always possible to predict how a patient’s behaviour may lead to violent or aggressive acts, but you should try to anticipate these events and protect others. Use of seclusion and restraint can lead to dissatisfaction and unhappiness in nurses, reflecting the emotional impact of this type of patient care. Therefore, you should only use these measures ethically and you should relate your feelings to other colleagues, to receive support.

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This chapter provides an overview of common ethical dilemmas encountered in nursing practice. You will encounter ethical dilemmas at some stage in your career. There are no easy answers for many of these scenarios and decision-making can be challenging. You should involve staff and colleagues when necessary and consult local ethics and professional guidelines. Ultimately, you should serve the best interests of the patient and adopt a sensitive and calm approach to problem solving. By utilising professional, ethical and legal frameworks, you minimise the risk of harm to the patient while preserving their rights.

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