Introduction: Nursing Ethical Dilemma Case Study
In the selected hypothetical case, a patient named Roderick Clark, a 66-year-old man diagnosed with cancer, receives chemotherapy and does not seem to cope with the treatment successfully. The adverse effects of chemotherapy, including nausea and vomiting, fatigue, and peripheral neuropathy, are evidently intense in Mr. Clark’s case. Nurses provide necessary support to the patient, including practical advice, such as consumption of ginger to alleviate nausea. However, Mr. Clark demonstrates signs of despair. During one of his conversations with a nurse named Melinda Lee, the patient confesses to having suicidal thoughts. He becomes agitated and asks Ms. Lee to keep this confession secret, and she promises not to tell anyone in order to calm him down. However, Ms. Lee faces an ethical dilemma and does not know whether she should or should not warn other health care providers. The dilemma can be addressed from three perspectives: principles of nursing ethics, ethical decision-making process, and implications for nursing practice.
Ethical Principles in Nursing: Autonomy and Veracity
Major principles of nursing ethics are autonomy, nonmaleficence, beneficence, and justice. The principle of autonomy is the first one to be considered in the presented case (Grace, 2017). This principle applies to cases in which patients make their own decisions concerning their health care and treatment. According to Grace (2017), the patients’ right to make such decisions should be recognized, respected, and fulfilled. There are cases in which patients may not be able to make independent decisions (e.g. if a patient is a young child or if the patient is diagnosed with a mental disease); however, in all other cases, the patients’ decisions should not be compromised. In the presented case, Mr. Clark’s ability to make decisions about his treatment is not doubted, and Ms. Lee should commit to the principle of autonomy and refrain from telling anyone something that the patient asked to keep secret.
Another ethical consideration is the principle of veracity. Grace (2017) defines veracity as “[t]ruthfulness in giving patients information about their healthcare needs” (p. 427). The author stresses that veracity is needed to ensure that patients’ choices and decisions are not only independent but also informed. In the presented situation, to follow the principle of veracity, Ms. Lee should explicitly explain to the patient that the lack of psychological support needed to address his suicidal thoughts may cause negative effects on the patient’s state and treatment. However, if the patient continues to refuse to reveal this information to other members of the medical staff, the nurse, from the perspective of autonomy, will not be able to tell anyone about Mr. Clark’s suicidal thoughts because it will mean not only violating his autonomous decision making but also breaking a promise, as Ms. Lee told Mr. Clark that she would keep his secret.
Ethical Principles in Nursing: Beneficence and Nonmaleficence
Two other principles of nursing ethics to be considered in the presented case are beneficence and nonmaleficence. Although many authors regard the principles as separate, Finkelman and Kenner (2013) combine it into one principle the meaning of which is to promote positive outcomes for the patient in every activity conducted by a nursing care provider and refraining from any actions that can potentially harm the patient. Going back to Mr. Clark, it should be recognized that his suicidal mood should be properly addressed as part of his treatment in the form of providing additional psychological support; if it is not, the patient’s state may deteriorate. Moreover, Mr. Clark may commit suicide unless he is properly assisted. To avoid this, i.e. to comply with the principle of nonmaleficence, Ms. Lee should warn other health care providers about Mr. Clark’s thoughts. Her silence in this case is regarded as an action (or non-action) that can harm the patient.
In addition, warning other health care providers can be regarded as a beneficent action because, once the care delivery team pays more attention to the patient’s psychological state, measures will be taken that can improve health outcomes for Mr. Clark. These measures may include not only support but also prescribing appropriate medications to cope with the depressive mood. Finkelman and Kenner (2013) stress that beneficence “involves awareness of the patient’s situation and needs” (p. 181); Mr. Clark’s need that should not be overlooked is to be encouraged to have a more positive attitude that will help him cope with a difficult treatment. This can be achieved by combining efforts of all the practitioners involved in delivering health care to him, but for this, Ms. Lee will need to tell them his secret.
Ethical Decision Making in Nursing
An ethical dilemma is a situation in which two or more ethical principles collide, and any possible decision will inevitably violate one of the principles. This is why, although the philosophy of care may be defined with the use of universal principles, there are no universal solutions for ethical dilemmas (Grace, 2017). Each case should be examined separately, and all the considerations and possible effects of every hypothetical decision need to be explored. This process constitutes ethical decision making. However, nurses do not have to be alone in this process. Barry and Edgman-Levitan (2012) propose the concept of shared decision making, meaning that patients and health care providers can discuss ethical dilemmas and other issues together, and this will improve the patient-centeredness of care. From this perspective, Ms. Lee should explain the dilemma that she faced to Mr. Clark, and he might reconsider his previous decision and allow the nurse to share his secret.
The ethical decision-making process can be stressful and cause moral distress (DeKeyser Ganz & Berkovitz, 2012). The type of Ms. Lee’s dilemma is rather rare, as it was not listed among frequently encountered types revealed by DeKeyser Ganz and Berkovitz (2012) in their study of nurses’ perceptions of ethical dilemmas (these included dealing with a patient or a family member who is insulting or violent, not revealing diagnosis- or treatment-related information to a patient due to the family’s request, providing insufficient information to patients during the informed consent process, and administering futile procedures and medical tests). However, Ms. Lee’s dilemma is still challenging and capable of negatively affecting her work because the patient’s life may be under threat, which makes the situation highly stressful.
To facilitate the decision-making process, decision-makers may find it helpful to break the process into stages. An example is the bioethical decision-making model; it divides the process into ten steps that can be grouped into research, preparation, action, and evaluation (“The bioethical decision,” n.d.). If applied to the presented case, the model will demonstrate that Ms. Lee, in addition to the considerations summarized in the previous sections, should identify all the individuals connected to the dilemma; apart from herself and the patient, the patient’s family members may be regarded as participants. Without imposing her beliefs on them (“The bioethical decision making model,” n.d.), Ms. Lee can try to explain to them that their extensive engagement in the process of care may have additional positive outcomes for the patient. With more family support, the patient may become willing to confess that he has suicidal thoughts and receive psychological assistance.
Implications for Nursing Practice
For any conceptual and theoretical perspectives, implications for nursing practice should be explained (Finkelman & Kenner, 2013). Upon reflecting on nursing ethics or applying a certain ethical decision-making model, Ms. Lee receives tools for addressing the dilemma she faces. Apart from the two initial possible decisions — to keep Mr. Clark’s confession secret or to tell other health care providers about it — she discovers other options, such as talking to the patient and explaining her dilemma to him or trying to extend the degree of family engagement that can help Mr. Clark make a different decision. These solutions can be ultimately more beneficial for the patient and less harmful for Ms. Lee’s integrity because they do not make her violate ethical principles.
In the presented case, the nurse cannot break the promise she gave to the patient because it would violate the patient’s autonomy. However, she cannot remain silent, either, because this would violate the principles of beneficence and nonmaleficence to which she should be committed in her work. In the ethical decision-making process, the nurse can find several additional instruments for addressing the dilemma. This shows that her reflection on nursing ethics concepts can improve her practice by proposing solutions to real-life dilemmas. Whatever decision Ms. Lee makes, proper ethical considerations, such as those described above, will help her ensure that her decision is optimal.
Barry, M. J., & Edgman-Levitan, S. (2012). Shared decision making — The pinnacle of patient-centered care. New England Journal of Medicine, 366(9), 780-781. The bioethical decision making model. (n.d.).
DeKeyser Ganz, F., & Berkovitz, K. (2012). Surgical nurses’ perceptions of ethical dilemmas, moral distress and quality of care. Journal of Advanced Nursing, 68(7), 1516-1525.
Finkelman, A., & Kenner, C. (2013). Professional nursing concepts: Competencies for quality leadership (2nd ed.). Jones & Bartlett Learning.
Grace, P. J. (2017). Nursing ethics and professional responsibility in advanced practice (3rd ed.). Jones & Bartlett Learning.