Nursing Ethical Dilemma
Dossey (2013) presented the prophetic words of the first nurse and a charismatic leader Florence Nightingale who envisioned that there would come the times when “every sick person will have the best chance for recovery” and nurse leaders “will arise, who have been personally experienced in the hard, practical work, the difficulties, and the joys of organizing nursing reforms” (p. 4). The integral and holistic perspective on nursing embodies the image of an ideal nurse of the future outlined in the report by the Institute of Medicine in 2010; a professional who will initiate innovative change and redesign in the nation’s healthcare system, as well as provide communities with high quality care. The holistic, integrative nursing focuses on a person as its core value and final goal. By focusing on the wholeness of a person, it integrates new theories, models, and information, and combines inter-professional efforts for the best quality service.
The ethical values and principles of a critical, evidence-based decision-making form the foundation of nurses’ integrity (Dossey, 2013) in fulfilling duties and providing efficient leadership of advance practice nurses (APNs). In the research, the notion of a transformative, charismatic, and authentic leader is associated with the concept of an ethical leader (Brown & Mitchell, 2010). Such leaders are positive role-models of ethical conduct; they transform their followers into moral leaders by empowering and inspiring them. Fair and trustworthy leaders, who ground on just moral reasoning and unambiguous moral rules, gain trust and respect towards themselves. Moreover, ethical leadership enhances followers’ personal and organizational effects, such as: job satisfaction, commitment to common goals, willingness to report problems to the seniors, and put extra efforts to do the job properly (Brown & Mitchell, 2010). It is especially important in light of peculiarities of nursing leadership, where it is vital to engage in successful interpersonal relationships with the patients and the members of the team of caregivers. This corresponds to the concept of patient- and relationship-centeredness of the modern healthcare (Dossey, 2013). Overall, one of the most challenging tasks in clinic practice settings is ethical decision-making, especially in cases of moral problems, or dilemmas when it is necessary to make a responsible justifiable choice between two conflicting courses of actions. This paper demonstrates an attempt to apply the principles of ethical decision-making with the purpose to produce a most appropriate ethical resolution of a clinical situation that presents an ethical dilemma.
To start the process of decision-making in our case, it is reasonable to gather information about the clinical situation, the parties involved, their values and duties, and their sets of beliefs that might possibly affect the process of providing care. In other words, one has to know enough information for the correct identification of the problem (Hamric & Delgado, 2014). Thus, a 30-year-old woman at 6 weeks gestation is diagnosed with a ruptured ectopic pregnancy. It is recommended that she undergoes an immediate surgery and accepts blood transfusions due to her dangerous level of the hemoglobin count. The clinical team wants to administer the blood since it is the most rational intervention in such cases. The female patient needs the prescribed treatment for life-saving purposes, but she refuses blood transfusions on religious grounds. Her religious community of Jehovah Witnesses (JW) grounds on the literal interpretation of the Bible and strictly prohibits consuming any products derived from human or animal blood. The woman is afraid to be disfellowshipped and excluded from the JW society, so she remains firm in her decision and does not consent to receive any blood. As a family nurse practitioner (FNP), I approached her husband and tried to explain the seriousness and details of his wife’s state and the importance of the intervention proposed by the health professionals. However, the husband, also a JW, supported her in refusal and did not attempt to persuade the woman into receiving the needed treatment. In the end, the patient went on to have a surgery without blood transfusion. During the procedure, her life was at risk due to the fact that the hemoglobin level dropped as low as 65 g/L. Fortunately, she survived.
At the next step of the decision-making framework, proposed by Purtilo and Doherty (as cited in Hamric & Delgado, 2014), it is necessary to identify the problem and its type. Our case belongs to ethical dilemmas since it presents a conflict “in which two opposing courses of action are both ethically justifiable but cannot both be satisfied” (Hamric & Delgado, 2014, p. 342). As it usually occurs with ethical dilemmas in nursing, moral issues of core values, here, of the JW religious group, and fundamental obligations were present (Hamric & Delgado, 2014). On the one hand, it was the duty of the healthcare providers to provide the best quality care for the patient. In this particular case, the intervention demanded blood transfusion to prevent the woman from the consequences of blood loss and critical hemoglobin count. However, conflicting demand implied the necessity to respect the patient’s religious belief, which forced her to refuse the blood transfusion. Here, caregivers had to choose between equally unacceptable alternatives because both of them seemed morally unsatisfactory: if one chooses to do the surgery and apply the transfusion, it would be for life-saving purposes but along with that present the violation of the patient’s autonomous decision. Otherwise, if a health professional chooses to reject the blood intervention, he or she would demonstrate the fulfillment of the principle of autonomy but it would be impossible in such a way to follow the principle of beneficence. In her situation, the female patient needed the surgery and blood transfusion badly; her health and life depended on it. In this particular case, the decision was made in favor of doing the best for the patient, and that was the surgery. It is evident that it was risky to violate the principle of autonomy since the woman was adult and in sound mind, so she was able to come up with an informed choice of whether to accept or refuse the proposed treatment (Hivey, Pace, Garside, & Wolf, 2009; Doyle, 2011; Bogaert and Ogunbanjo, 2013). She refused, and her decision had to be respected. Overall, a medical team has to take a big risk choosing to ignore patients’ right for the autonomous choice of treatment.
The ethical dispute under the analysis was characterized by a difference in values between the patient, with her religious beliefs contradicting this particular medical method, and professional values of the clinicians who were directed in their choice of treatment by the principles of beneficence (“the duty to do good and prevent or remove harm”) and non-maleficence (“the duty not to inflict harm or evil”) (Hamric & Delgado, 2014, p. 336). In my opinion, for most medical workers, personal values, including religious beliefs, give way to the professional values of high quality care and struggling for life. For this reason, it turns out challenging to accept that a patient him- or herself can present obstacles in treatment.
I also find characteristics of communication origin in this ethical dilemma. APNs must employ communication skills in providing the patient with all the necessary information concerning the vitality of blood transfusion in the condition of low hemoglobin count and possible consequences of refuse, as well as persuading the patient to consent to the most appropriate course of action from the medical point of view. APNs and FNPs must educate themselves and develop managerial roles of the “Negotiator” and a “Spokesperson” to perform successfully in the interpersonal relationships context (Mintzberg, 1973). I should improve my competence in leading effective discussions within the team of professionals and with patients and their families through presenting the information in a precise and succinct manner. Except for brilliant verbal skills, one should not forget that negotiating competence includes listening skills and capacities for empathy, for tolerance to beliefs. In particular, the ability to listen and understand the interlocutor’s perspective is vital for solving ethical disputes involving patients and their families. Additionally, Hamric and Delgado (2014) suggest that to facilitate a successful resolution it is effective to focus on shared (but not conflicting) values and goals and collaborate in the process of achieving them.
The factors that inhibited the constructive decision of this moral issue were associated with organizational and environmental barriers (Hamric & Delgado, 2014, p. 353). As a FNP, particularly in this dilemma concerning patients’ religious beliefs versus traditional medical practice, I felt the lack of an effective co-operation with internal and external resource centers, which could assist me with advice and consultation. For instance, it would be reasonable and effective for the best ethical decision to acquire support from social work staff, ethics committees, ethics consultation services. Resources outside the institution that could be of assistance in this situation include the ANA’s Center on Ethics and Human Rights, ethics groups and centers (Hamric & Delgado, 2014, p. 352). It is really difficult to conduct the process of resolution individually, without engaging appropriate resources.
Speaking of internal barriers, I should recognize that I felt the lack of confidence in my ability to effectively resolve this ethical dilemma since the stakes were high: the life and health of the woman. Besides, it was really difficult for me to accept the fact that some people, because of certain religious demands of their community can sacrifice their lives and even the lives of their beloved. It was challenging to demonstrate the tolerance to such an extent that to understand these dangerous personal biases. However, I clearly realize that my personal views should not interfere with the quality of the service I provide and the relationships with the patients and their family members.
The current ethical dilemma involves the counteracting of certain principles, for instance, the principle of beneficence (which motivates to perform the surgery and blood transfusion for the good of the patient) versus the principle of autonomy: the woman was adult and in sound mind, so she had the right to choose the treatment or refuse any suggested method (Doyle, 2011; Panico, Jenq, & Brewster, 2011; Hivey et al., 2009). The issue of beneficence is frequently regarded in the research versus respect for autonomy. As Macchiocchi (2009) states, “balancing respect for autonomy and beneficence is one of the most common problems” medical professionals face on a daily basis (p. 72). Beneficence implies distinguishing what is good for a particular person in a specific situation. However, it is not easy to unambigously define what a person’s best interest is. And sometimes, as Macchiocchi (2009) puts it, “acting in a person’s ‘presumed best interest’ may not necessarily be a beneficent act” (p. 27).
As Macchiocchi (2009) claims, healthcare workers have got clear-cut ethical statements, since the times of Florence Nightingale who began nursing as an ethical caring (Dossey, 2013), in the form of ethical models and theories. I believe that if this situation happens again I will choose the principle-based model (Hamric & Delgado, 2014, p. 336) and combine it with casuistry. On the one hand, by using the principles of beneficence, nonmaleficence, respect for autonomy, justice, and others, clinicians can examine the ethical implications of clinical decisions and interventions (Macchiocchi, 2009; Hivey et al., 2009; Idris & Nalliah, 2014; Hamric & Delgado, 2014). In certain cases although, particularly with JW, it is not so easy to unambiguously determine what principle to follow since some of them can confront each other, as, for instance, the principle of beneficence versus the principle of a JW patient’s autonomy to make own refusal or consent. If one applies the casuistic theory (Hamric & Delgado, 2014) to this particular clinical situation, one will discover the following state of affairs. If a health professional chooses to make a decision based on the previous cases described and analyzed in research, one would see that the court frequently finds the professional guilty of battery and coercion when he / she violates the principle of autonomy for the sake of doing good, or the principle of beneficence (Panico et al., 2011; Doyle, 2011; Idris & Nalliah, 2014). As Doyle (2011) states, a clinician must provide a patient’s informed consent as far as the benefits and risks of receiving or refusing blood transfusions are concerned. He then adds that in Canada and the USA, as well as in other European countries, common law prioritizes a person’s legal right to refuse or consent to treatment. Thus, Doyle (2011) describes a number of cases concerning the treatment of JW. For instance, the landmark legal case of Malette vs. Shulman, which took place in Canada, centered on patient autonomy. As a result, the doctor who administered a blood transfusion to an unconscious JW patient out of clinical necessity for life-saving purposes, was found liable for battery by the court. Such saving actions of a doctor are interpreted as the violation of a person’s right to control own body and disrespect for his / her religious values. In the USA, similar results took place in case of Schloendorff vs. Society of New York Hospital when a surgery was performed without her consent. The court established the notion of informed consent and the right of every adult human being with sound mind “to determine what shall be done with his own body” (Doyle, 2011, p. ). All in all, the principle of beneficence is unable to surpass the principle of respect for a person’s autonomy. So, one has to control own emotions, carefully consider all the factors present in a particular clinical situation, all the legal and other factors, and make the most reasonable decision, which will provide care and also will not affect a medical professional’s integrity.
To continue the debate, it is interesting to refer to Bogaert and Ogunbanjo (2013) who suggest an alternative how to take the most efficient ethical decision in case of JW whose religious beliefs prohibit consuming blood and its products in any possible ways. The authors’ claim about new rules and possibility of their different interpretation seems productive in healthcare context and patients’ beneficence. It is known that the representatives of this religious community reject blood products even in the face of death because, as Bogaert and Ogunbanjo (2013) put it, they are awfully frightened to be excluded from their church and face “disfellowshipping”. Since they have the practice of obligations among the fellow members to report another member’s divergence from ideology, every JW is afraid to consent to blood transfusion and thus face the exclusion from the religious community. It obviously means that the motives of refusing from blood in the emergency are not really dictated by one’s own well-being and informed conscious consent. In my opinion, this religious demand is coercion in itself and imposing someone else’s views on a person. Moreover, it is irrational to suppose that a person can consciously choose to die instead of to live or to be ill and suffer instead of to get the treatment, which can save from pain and sufferings. So, the views are imposed and infringed. Then, since a nurse, or any other member of a healthcare team is obliged to follow the ethical principle of a patient’s autonomy and own choice, it is thus possible to state that such decision of a patient is not autonomous in its proper sense: it is infringed by the religious group’s instructions. Consequently, a caregiver receives a moral right and even duty to try and influence the person’s decision in the direction of consent.
For example, it is important to inform the JW patient that since 1996 many JW have expressed their dissent to the blood policy of the community, questioned the rigidity of some of the Jehovah’s Witnesses practices, and proved their views with excerpts from the Bible. They state that refusal from blood transfusions is based on the wrong interpretations of the holly text. This group of dissidents is called the Associated Jehovah's Witnesses for Reform on Blood and they even own a website www.ajwrb.org, where a person can get acquainted with their view on the JW blood policy as “complicated web of contradictory rules and conditions strictly enforced without biblical basis” (Bogaert & Ogunbanjo, 2013). The theorists call the JW’s religious prescription intriguing and controversial. While it prohibits transfusion of any red and white blood cells products many current treatment modalities are available and are considered the matter of personal choice. Here belong, for example, recombinant human erythropoietin, albumin, and recombinant activated factor VIIa, autologous autotransfusion and isovolaemic haemodilution (Bogaert & Ogunbanjo, 2013). Moreover, it seems productive enough to explain to a patient that medical workers are ruled in the professional behavior by the rule of confidentiality: “the duty not to disclose information shared in an intimate and trusted manner” (Hamric & Delgado, 2014, p. 336). So, a healthcare provider must ensure medical confidentiality and explain that there is no risk that other members of the religious group will find out about any interventions; neither the patient’s information nor his / her medical history can be available to others.
Overall, to make a reasonable decision in an ethically complicated situation, it is necessary to undergo a deliberate consideration of every detail and step-by-step reflection of all the factors. Research has suggested a number of various reflection models with precise algorithms of analysis (Hivey, 2009; Idris & Nalliah, 2014; Hamric & Delgado, 2014) for the best outcomes for both the quality care of patients and the integrity of healthcarers (Dossey, 2013). Hence, by utilizing ethical decision models and scientific evidence, it becomes possible for an APN or other clinicians to arrive at the most appropriate decision for patient care. Along with that, such ethical decision-making process allows health professionals to remain within the boundaries of law, social justice, and professional integrity.
I understand that Panico et al. (2011) reasonably state that it is important for a team of clinicians to perceive JW philosophy to be able to constructively deal with them in the process of choosing the treatment and decision-making. Undoubtedly, it is important to treat them with respect to each individual and his / her beliefs. For me personally, as I have already mentioned earlier in the paper, it is challenging to keep quiet and understand people who sacrifice their lives and those of their beloved with the purpose of blindly following the demands of the religious community. Moreover, this community seems to have numerous contradictions in its demands and interpretations. So, it wakes in me strong negative emotions to watch people forget about the highest existing value – the value of human life. Since a lot of JW’s members are not even aware of the new blood product regulations, an individual cannot make an informed autonomous choice of the best available treatment.
It is clear that APNs and FNPs, as well as other members of medical teams have to work hard to keep moral incidents from occurring. I agree with Hamric & Delgado (2014) that the only way to achieve this is through education, empowerment, and problem solving.