Healthcare Providers: Legal and Ethical Issues

The Scenario

Marlene is a 15-year old girl who feels unwell after a night out with her boyfriend during which time they had sexual intercourse. Marlene suffers chronic stomach pains for a week afterward, and, fearing that she might be pregnant, attends her GP, Dr. Scott. Before revealing anything about herself, however, Marlene seeks, and receives, assurances from Dr. Scott that what they discuss will go no further than the surgery – Marlene’s parents and sisters are very religious and she does not want them knowing about her private life. Dr. Scott quickly establishes that Marlene had her period two days before and so could not be pregnant, but he becomes worried that something far more life-threatening may be at work.

A thorough examination leaves Dr. Scott with the strong suspicion that Marlene may be suffering from colorectal cancer, which can be fatal if not caught in the early stages and aggressively treated. Dr. Scott asks if he can take blood from Marlene for “more tests” and she agrees. After drawing the blood he explains that she might be suffering from a genetic condition that runs in her family and that she should discuss this with her parents and sisters, who should also come in for testing.

Marlene is horrified at the thought of this and refuses, despite Dr. Scott’s attempts to persuade her otherwise. Dr. Scott does not know the family, but he does know that Marlene’s sisters both attend the same school as his own daughter. Marlene becomes sullen and asks if she can “go now”. Dr. Scott agrees and asks her to make another appointment to see him in two weeks’ time. Dr. Scott follows Marlene to the reception area and asks the nurse to send off the two tubes of Marlene’s blood for testing. He returns to his office and the nurse becomes distracted by another patient, leaving the test tubes on the desk.

Marlene surreptitiously removes them thinking “I don’t want anyone interfering with my blood; doctors can’t be trusted; I’ll take my chances”. She then leaves the surgery without making another appointment. She never returns to see Dr. Scott. One year later Marlene’s sister, Ethel, develops symptoms of colorectal cancer. It proves to be too late at this stage to prevent the spread of her cancer and she is diagnosed as terminal.

Ethical Issues Arising from the Scenario concerning Marlene, Dr. Scott and Ethel

Autonomy

Potter and Perry (2010) argue that “the principle of autonomy is based on the assertion that individuals have the right to determine their own actions and the freedom to make their own decisions” (p. 119).¹ Respect for the individual is the keystone of this principle.

Autonomous decisions are based on: individuals’ values, adequate information, freedom from coercion and reason and deliberation. Examples of autonomy in healthcare include: refusing treatment, giving consent for treatment or procedures, and obtaining information regarding results of tests and treatment options (Clark & Taxis, 2003).² Autonomy is well illustrated in the above scenario. After explaining to Marlene about her possible health condition Dr. Scott allowed Marlene to make her own decision. Taking into consideration her family’s religious beliefs, Marlene decided not to reveal her health condition to her family to avoid embarrassing them.

Beneficence

Beneficence is commonly defined as the doing of good and is often thought to be the most critical ethical principle in health care.³ Fundamentally, the principle requires one to always consider his actions in the context of enhancing the welfare of the patient. This however becomes a challenge when what is generally considered to be good for the patient also brings harm to the patient or conflicts with the patient’s desire.

Beneficence is also illustrated in the above scenario through Dr. Scott. Dr. Scott is sincerely concerned about Marlene’s health and advice her to undergo a series of tests that would have further established the illness she was suffering from. Dr. Scott also portrays the principle of beneficence when he advises Marlene to inform her family about the possibility of the genetic disease so that her family could go for tests and treatment in case any of them was found to be at risk of the disease.

Nonmaleficence

Nonmaleficence is defined as “the duty to do no harm,” (Hamric, 2002, p. 177).⁴ This principle is ingrained in the Code of Ethics for Nurses. It asserts that the health care professional “must not knowingly act in a manner that would intentionally harm the patient,” (Marshall, 2001, p. 12).⁵ Some treatments have high risks of causing harm to the patient, but they also have great good for the patient, for instance, chemotherapy and bone marrow transplant which can make the patient weaker and vulnerable to opportunistic infections but which may cure the illness. In addition, healthcare professionals may have some information about a patient but may fail to act on the information which may in turn lead to adverse effects on the patient.

In the scenario, nonmaleficence is well illustrated through Ethel. Dr. Scott had information about Marlene’s possible health condition and the fact that the disease is hereditary. As a result, Marlene’s family members were also at risk of developing the disease. Even though Dr. Scott had this information, he failed to act on it by following up on Marlene and information her family about the condition. As a result, he failed to execute his duty of doing no harm. This led Ethel (Marlene’s sister) to develop the disease without knowing until it was discovered when it was too late.

Veracity

Veracity is defined as “telling the truth,” (Chitty & Black, 2007, p. 120).⁶ Telling the truth has usually been regarded as a basic necessity in human relations. Ingrained in the healthcare provider-patient relationships is the assumption that the healthcare providers will be honest with their patients. However, in some cases healthcare practitioners particularly nurses are limited by an organizational system that limits them on what they can tell the patient.

In such cases, the healthcare providers engage in involuntary withholding of the truth. Voluntary deception is however considered to be immoral.⁷ Persons in need of health care may also not be totally honest when giving their health information. Likewise, healthcare professionals may not be honest when responding to patients’ inquiries for information related to their treatment or prognosis. Reasons for such dishonesty include the notion that patients would be better off not knowing certain information or that they are not capable of understanding the information.⁸

Veracity is clearly evident in the scenario. When Marlene goes to Dr. Scott concerned that she could be pregnant, Dr. Scott examines her and confirms to her that she cannot be possibly pregnant because she had just received her menstruation two days earlier. However, instead of stopping there, Dr. Scott proceeds and informs Marlene that she could be having colorectal cancer which is hereditary. Dr. Scott also informs Marlene that the disease could be running in her family and so it was best if her family knew about the situation so as to avoid any adverse events in the future. Thus, Dr. Scott was completely honest with Marlene.

However, the lack of veracity was evident in the relationship between Dr. Scott and Ethel. Dr. Scott knew that the probability of one of Marlene’s family members to suffer from the disease was high. Although Marlene was 15 years old, she could be considered as Gillick competent and hence the need for the doctor to maintain the confidentiality of the information given to him. However, the fact that there was a third party involved – Marlene’s family members – who were likely to be affected by her condition, Dr. Scott should have informed her family about the likelihood of the hereditary condition running in the family.⁹

Unfortunately, he failed to tell the truth to Marlene’s family and this led to the fatal ending of Ethel’s life. If Dr. Scott had told the truth to Marlene’s family early enough, Marlene’s family members would have been tested for colorectal cancer and therefore Ethel’s condition would have been detected and treated earlier on.

Fidelity

Fidelity refers to faithfulness or honoring one’s commitments or promises to patients.¹⁰ The healthcare professional is supposed to be faithful to his or her role by seriously taking into consideration all ethical responsibilities related to the practice. When healthcare professionals accept patients, they are bound to offer the best care to them. Failure to do so is unethical. Commitment to promises, commitments and agreements builds the trust that is crucial for the provider-patient relationship.¹¹

The above-mentioned scenario illustrates both fidelity and infidelity on the part of Dr. Scott. On the one hand, Dr. Scott portrays fidelity by the fact that he promised Marlene that what they discussed about her condition would not leave the confines of the examination room. True to his word, Dr. Scott kept mum about Marlene’s condition and did not disclose the details to her family even when logic told him otherwise.

On the other hand, Dr. Scott also portrays infidelity. By going to Dr. Scott for examination and medical advice, a relationship was formed between Dr. Scott and Marlene which implied that Dr. Scott was obligated to do what was best for Marlene as far as her medical and health condition was concerned. Unfortunately, Dr. Scott failed to honor his obligation. First and foremost, he failed to follow up on Marlene when she took off with her blood samples and thus no tests could be performed on her.¹²

Dr. Scott could have acted on Marlene’s action by following up on her and ensuring that she undergoes the tests to rule out or confirm that she was suffering from colorectal cancer. Moreover, knowing that the disease is hereditary, Dr. Scott should also have informed Marlene’s family about his suspicions and advice them to undergo tests so as to save their lives. This is because even if Dr. Scott was bound by his professional standards to be confidential, there was a third party involved in the situation.

Legal Issues Arising from the Scenario with Respect to Marlene, Dr. Scott and Ethel

Informed Consent

This principle requires all patients to be granted the chance to give informed consent before any treatment except when there is a life-threatening emergency (Ellenchild-Pinch & Graves, 2000).¹³ The consent must be voluntary, must be given by an individual with the capacity and competence to understand, and should be based on adequate information.¹⁴ In the scenario mentioned above, the issue of informed consent is illustrated when Dr. Scott explains to Marlene his suspicions that she could be suffering from colorectal cancer. He then proceeds to ask her for permission to draw blood from her for further tests which Marlene accepts.

Thus, Marlene gives the consent for blood samples to be taken to facilitate additional tests. This consent was an informed one. Nevertheless, the further tests required were not possible because Marlene took off with the blood samples and failed to make another appointment with her doctor. At this point, Dr. Scott had no power over Marlene’s health condition and decision because even though she was 15 years, she was Gillick competent.¹⁵

Negligence

Negligence is defined as “the failure to act as a reasonably prudent person would have acted in specific circumstances,” (Matzo, Sherman, Nelson-Marten, Rhome & Grant, 2004, p. 62).¹⁶ In the above-mentioned scenario, negligence is illustrated by the failure of Dr. Scott to inform Marlene’s family about the genetic disease they could be suffering from. This led to Ethel’s terminal illness because the disease was discovered when it was already too late and nothing could be done to cure her.

Negligence was also illustrated on the part of the nurse who was given the blood samples to take to the laboratory for further testing. Instead of doing so, the nurse became involved with other matters and provided an opportunity for Marlene to take off with the blood samples. This prevented Dr. Scott from conducting further tests and establishing her health condition.

Confidentiality

Confidentiality refers to maintaining privacy of the health information of patients.¹⁷ In the scenario mentioned above, confidentiality is highly maintained by Dr. Scott. Dr. Scott keeps his word about not disclosing Marlene’s health condition to her family. However, the issue of confidentiality raises questions especially when third parties are involved. If a third party is likely to be affected by failure to disclose the information of a patient, then healthcare providers have an obligation to disclose such information.¹⁸ In the scenario mentioned above, the third party is her family members and more so Ethel, her sister. The failure of Dr. Scott to disclose the information about the genetic disease led to the discovery of Ethel’s condition when she was already terminally ill and nothing could be done about it.

Conclusion

In the provision of healthcare, healthcare providers are often faced with several ethical and legal issues which have a significant impact on their work. These issues, on many occasions, contradict each other thus bringing about conflicts for the healthcare provider. This paper has analyzed the ethical and legal issues that arose from the mentioned scenario. These issues include autonomy, beneficence, nonmaleficence, veracity, fidelity, informed consent, negligence and confidentiality. It is important to note that the ethical and legal issues that confront healthcare providers are affected by many factors such as the age of the patient and the potential risk to a third party. Thus, actions taken by healthcare providers while executing their professional duties differ from one situation to another.

Reference List

American Nurses Association, Code of ethics for nurses with interpretive statements, American Nurses Association, Silver Spring, 2001.

Andrews, D, ‘Fostering ethical competency: An ongoing staff development process that encourages professional growth and staff satisfaction’, Journal of Continuing Education in Nursing, vol. 35, 2004, pp. 27–33.

Chitty, K & Black, B, Professional nursing: concepts & challenges, Elsevier Philadelphia, 2007.

Clark, A & Taxis, J, ‘Developing ethical competence in nursing personnel’, Clinical Nurse Specialist, vol. 17, 2003, pp. 236–237.

Cohen, J & Erickson, J, ‘Ethical dilemmas and moral distress in Oncology’, Nursing Practice, vol. 10, no. 6, 2007, pp. 775-780.

Dahlin, C, ‘Ethics in end-of-life care’, Journal of Hospice and Palliative Nursing, vol. 6, no.1, 2004, pp. 1-2.

Eddie, F, ‘Moral and ethical dilemmas in relation to research projects’, British Journal of Nursing, vol. 3, no. 4, 1994, pp. 182-184.

Ellenchild-Pinch, W & Graves, J, ‘Using Web-based discussion as a teaching strategy: Bioethics as an exemplar,’ Journal of Advanced Nursing, vol. 32, 2004, pp. 704–712.

Erichsen, E, Danielsson, E & Friedrichsen, M, ‘A phenomenological study of nurses’ understanding of honesty in palliative care’, Nursing Ethics, vol. 17, no. 1, 2010, pp. 39-50.

Hamric, A, ‘Bridging the gap between ethics and clinical practice’, Nursing Outlook, vol. 50, 2002, pp. 176–178.

Jameton, A, ‘Dilemmas of moral distress: Moral responsibility and nursing practice’, Clinical Issues in Perinatal and Women’s Health Nursing, vol. 4, 1993, pp. 542–551.

Kelly, B, ‘Preserving moral integrity: A follow-up study with new graduate nurses’, Journal of Advanced Nursing, vol. 28, 1998, pp. 1134–1145.

Lakin, M, Ethical issues in the psychotherapies, Elsevier Saunders, Philadelphia, 1988.

Layman, E, ‘Human experimentation: Historical perspective of breaches of ethics in US health care’, The Health Care Manager, vol. 28, no. 4, 2009, pp. 354-374.

Marshall, P, ‘End of life care: ethical issues’, Kansas Nurse, vol. 7, no. 4–7, 2001, pp. 11–12.

Matzo, M, Sherman, D, Nelson-Marten, P, Rhome, A & Grant, M, ‘Ethical and legal issues in end-of-life care: Content of the End-of-Life Nursing Education Consortium curriculum and teaching strategies’, Journal for Nurses in Staff Development, vol. 20, 2004, pp. 59–66.

Potter, P & Perry, A, Fundamentals of Nursing, Elsevier, Philadelphia, 2010.

Purtillo, R, Ethical dimensions in the health professions, Elsevier Saunders, Philadelphia, 2005.

Footnotes

1. P Potter & A Perry, Fundamentals of Nursing, Elsevier, Philadelphia, 2010.
2. A Clark & J Taxis, ‘Developing ethical competence in nursing personnel’, Clinical Nurse Specialist, vol. 17, 2003, pp. 236–237.
3. American Nurses Association, Code of ethics for nurses with interpretive statements, American Nurses Association, Silver Spring, 2003.
4. A Hamric, ‘Bridging the gap between ethics and clinical practice’, Nursing Outlook, vol. 50, 2002, pp. 176–178.
5. P Marshall, ‘End of life care: ethical issues’, Kansas Nurse, vol. 7, no. 4–7, pp. 11–12.
6. K Chitty & B Black, Professional nursing: concepts & challenges, Elsevier, Philadelphia, 2007.
7. D Andrews, ‘Fostering ethical competency: An ongoing staff development process that encourages professional growth and staff satisfaction’, Journal of Continuing Education in Nursing, vol. 35, 2004, pp. 27–33.
8. E Erichsen, E Danielsson & M Friedrichsen, ‘A phenomenological study of nurses’ understanding of honesty in palliative care’, Nursing Ethics, vol. 17, no. 1, 2010, pp. 39-50.
9. R Purtillo, Ethical dimensions in the health professions, Elsevier Saunders, Philadelphia, 2005.
10. F Eddie, ‘Moral and ethical dilemmas in relation to research projects’, British Journal of Nursing, vol. 3, no. 4, 1994, pp. 182-184.
11. A Hamric, ‘Bridging the gap between ethics and clinical practice’, Nursing Outlook, vol. 50, 2002, pp. 176–178.
12. B Kelly, ‘Preserving moral integrity: A follow-up study with new graduate nurses’, Journal of Advanced Nursing, vol. 28, 1998, pp. 1134–1145.
13. W Ellenchild-Pinch & J Graves, ‘Using Web-based discussion as a teaching strategy: Bioethics as an exemplar’, Journal of Advanced Nursing, vol. 32, 2000, pp. 704–712.
14. J Cohen & J Erickson, ‘Ethical dilemmas and moral distress in Oncology’, Nursing Practice, vol. 10, no. 6, 2007, pp. 775-780.
15. A Jameton, ‘Dilemmas of moral distress: Moral responsibility and nursing practice’, Clinical Issues in Perinatal and Women’s Health Nursing, vol. 4, 1993, pp. 542–551.
16. M Matzo, D Sherman, P Nelson-Marten, A Rhome & M Grant, ‘Ethical and legal issues in end-of-life care: Content of the End-of-Life Nursing Education Consortium curriculum and teaching strategies’, Journal for Nurses in Staff Development, vol. 20, 2004, pp. 59–66.
17. M Lakin, Ethical issues in the psychotherapies, Elsevier Saunders, Philadelphia, 1988.
18. C Dahlin, ‘Ethics in end-of-life care’, Journal of Hospice and Palliative Nursing, vol. 6, no. 1, 2004, pp. 1-2.