Nurses should be guided by both ethical and legal concerns when dealing with patients. The main advantage to nurses is that most laws have been enacted to reinforce the six bioethics principles. For example, the Bakers Act supports distributive justice when a patient is in need of urgent attention, irrespective of the patient’s economic status. The Self-determination Act reinforces the patient’s autonomy. There is a concern about the reducing availability of insurance to cover medical practitioner malpractice. The legal cases portray that the patient’s autonomy against a nurse acting in the best interest of the patient is one of the most common ethical issues.
Nurses are guided by six major principles of ethics when dealing with ethical dilemmas. The six principles include autonomy (personal freedom), nonmaleficence (do no harm), justice (fairness), veracity (truthfulness), fidelity (loyalty) (Ethical and legal practice, 2014). These principles help nurses to maintain ethical standards in areas not addressed by the law. First, nurses must consider what the law states, before considering ethical issues. Lawsuits emerging from the suspected illegal conduct of medical practitioners have resulted in insurance premiums increasing above what practitioners are willing to pay (Chapter 2: Legal, ethical, and safety issues in the healthcare workplace, 2012). In some states (U.S.), the number of insurance companies covering malpractice has reduced drastically.
The bioethical principle of justice is difficult to uphold when financial constraints are the main consideration. Parker (2007) describes a case, where the nurse had received an order to discharge a homeless patient. The patient was recovering from pneumonia. The nurse was aware that discharging the patient was not in the best interest of the patient because the patient would not receive essential care after discharge. It was an ethical dilemma for the nurse because discharging the patient would have worsened his condition. However, the nurse had to obey the hospital’s policy. The best the facility could do was to check whether a not-for-profit facility could accept to admit the patient for a longer period.
The law protects distributive justice when the patient arrives at a facility with an emergency medical condition. According to the Baker Act (Emergency Medical Conditions, EMTALA, and Hospital Transfers, n.d.), it is unacceptable for a medical facility to turn away a patient with a condition requiring urgent attention. According to the law, the right of the patient ends after 72 hours from the time the patient was examined by a doctor. The patient may be discharged before the 72 hours elapse, provided that his/her condition has stabilized. The discharging hospital has a duty to contact the receiving institution. In the case of discharging the patient recovering from pneumonia, the facility has the duty to seek a receiving facility. However, they are not compelled by law to continue to hold the patient involuntarily.
Patients may choose a nursing home, depending on their wish not to be resuscitated. Rosenblatt (2013) discusses a case, where the nurse observed a patient collapse in the senior residence. The nurse could not conduct CPR because it was the policy of the residence. In this case, the nurse refused to allow someone else to conduct the CPR. It may appear that the nurse had caused some harm. However, under the autonomy of the patient, the nurse acted in accordance with the law. Bratcher et al. (2011) explain that some nursing homes are allowed to avoid resuscitating patients because it is their policy and all patients are admitted based on the DNR (Do Not Resuscitate) order. In legal and ethical issues, the wishes of the patient are stronger than any other consideration.
In a similar case, an anesthesiologist and a nurse had completed intubation, after considering it necessary for the patient’s survival (Bosek, 2009). The patient’s family arrived to see the patient, as the nurses were preparing to transfer the patient to a facility. The patient’s family complained that the patient’s wish was DNR/DNI (Bosek, 2009). In this case, the nurse and the anesthesiologist had very little time to determine whether the DNR/DNI order existed. The nurses responded in a way that was considered to be in the best interest of the patient, considering all available information at the moment. The patient’s right to accept or refuse treatment supersedes the nurse’s discretion. In the absence of advance directives, the nurse may act in the best interest of the patient.
The requirement of confidentiality in genetic and genomic issues is based on honoring the patient’s autonomy. Huddleston (2013) discusses a case, where a woman was undergoing a different test and was discovered to have BRCA1 (breast cancer susceptibility gene). In a similar case, protecting the patient’s autonomy should be given the first priority. The patient had a right to refuse to be informed about the discovery. The patient would have chosen not to tell her family members, who had an interest in the discovery. The woman’s daughter, sister, and mother had a fifty-percent chance of having a similar genetic problem (Huddleston, 2013). Lea (2008) suggests that the nurse had no legal basis to violate the patient-nurse relationship and tell other family members about the new development. According to the American Nursing Association guidelines, Lea (2008) explains that the nurse needed to seek advice from the ethics board within the institution on how to solve the matter. Harm might have occurred to other family members if they were not notified in a timely manner, which would have prompted them to take a breast cancer test. The ability to cure cancer depends on its early detection. However, the nurse must first protect the patient’s autonomy.
The autonomy of the patient is one of the ethical issues that appear frequently. Bratcher et al. (2011) discuss the case of Quinlan, which involved a lawsuit by the hospital against the patient’s family. Quinlan stopped breathing in April 1975 and was hospitalized for a long period. The family wanted the ventilator shut down. The hospital wanted to protect the patient’s autonomy. It was determined that Quinlan’s condition could not improve. The court relied on verbal information from a witness to determine that it was Quinlan’s wish to have the life-sustaining equipment shut down (Bratcher et al., 2011). The hospital sought to protect the patient’s autonomy to avoid unethical conduct.
In the Nancy Cruzan case, the family wanted the feeding tube removed when the hospital did not want it removed (Bratcher et al., 2011). The court relied on verbal evidence to determine that the patient would not want to be sustained on a feeding tube. The judge ordered that the feeding tube be removed. In a similar case, Theresa Schiavo’s parents disputed the removal of a feeding tube against her husband. The patient suffered cardiac arrest in February 1990 and the case began 8 years later (Bratcher et al., 2011). The court ruled that the feeding tube should be removed, after determining that Schiavo would not want to be sustained by the feeding tube. Schiavo passed away two weeks later from starvation, which was considered cruel. However, hastening the patient’s death would have been illegal.
The Self-determination Act provides guidance on educating patients on advance directives. In the three cases involving the removal of life-sustaining-equipment, there were no written directives from the patients. The court established that the patients could not regain the ability to make personal directives or to recover from sickness. The Self-determination Act of 1990 requires that nurses/ surrogates to determine that the patient’s wishes are not coerced and reliable, the patient is unlikely to recover and regain competence, and that written and oral statements are considered (Bratcher et al., 2011).
Allowing time for informed consent may need better communication skills from the nurse. In a different case, a nurse was directed to place a PICC line in a patient (Bosek, 2009). The patient was elderly and appeared hysterical about the procedure. The nurse took some time to explain the need of the PICC line to the patient. She also gave the patient time to make a decision. Eventually, the patient agreed to have the PICC line placed (Bosek, 2009). In this case, placing the PICC line is in the best interest of the patient, but placing it without the patient’s consent is illegal. Without placing it, harm could occur, which is illegal based on the standard of care. The nurse had to inform the patient to allow the patient make informed consent.
The concept of paternalism may sometimes prevail when the harm caused to a patient is continuous. Paternalism is the violation of a person’s autonomy to act in a manner considered to be in the best interest of the patient (Gilliland, 2010). Gilliland (2010) discusses a case involving Mrs. Smith, a 76-year-old woman, who lived with her daughter, Betty. Mrs. Smith shared with the nurse about abuses committed by Betty. Mrs. Smith explained to the nurse that she had requested to be transferred to her other daughter’s house, but Betty did not want the idea. Betty withdrew money from her mother’s checking account to purchase clothes and jewelry without her consent. Betty used to withhold the insulin her mother used to control diabetes, until late in the night (Gilliland, 2010). The patient’s autonomy would require the nurse to maintain the patient-nurse confidentiality. Gilliland (2010) explains that the nurse could follow a systematic approach to arrive at the right decision. The nurse could assume paternalistic rights and make decisions that reduce the suffering of Mrs. Smith.
Solving Mrs. Smith case required the nurse to evaluate the values and the culture of the patient. The nurse could first arrange for Mrs. Smith’s transfer into her other daughter’s house to avoid retaliation from Betty (Gilliland, 2010). Betty was abusive physically and verbally to her mother. Moving the mother could have affected Betty’s psychological well-being, which required that Betty’s problem be addressed as well.
The analysis shows that a nurse should understand that upholding the patient’s autonomy is the most important ethical principle, which is also supported by the law. In some cases, the patient is in a coma for a long period. Ethics expects autonomy, but the law prohibits hastening death using unnatural means. In cases involving life-sustaining-equipment, nurses and institutions have defended the ethical concerns. In some cases, under paternalism, a nurse has to violate the patient’s autonomy to prevent the continuous suffering of the patient. Financial constraints affecting the facility and individuals are one of the major issues that create the ethical dilemmas in nursing.
Bosek, M. (2009). Identifying ethical issues from the perspective of the registered nurse. JONA’S Healthcare Law, Ethics, and Regulation, 11(3), 91-100. Web.
Bratcher, R., Farrell, J., Stevens, K., & Vanderground, K. (2011). Chapter 25: Ethical and legal issues. Web.
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Emergency medical conditions, EMTALA, and hospital transfers. (n.d.). Web.
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Gilliland, M. (2010). Making for nurses confronted with ethical problems involving elder abuse [Press release]. Web.
Huddleston, K. (2013). Ethics: The challenge of ethical, legal, and social implications (ELSI) in genomic nursing. OJIN: The Online Journal of Issues in Nursing, 19(1), 1-7. Web.
Lea, D. (2008). Genetic and genomic healthcare: ethical issues of importance to nurses. OJIN: The Online Journal of Issues in Nursing, 13(1), 1-7. Web.
Parker, F. (2007). Ethics column: “the power of one”. OJIN: Online Journal of Issues in Nursing, 13(1), 1-7. Web.
Rosenblatt, C. (2013). Nurse refuses to give CPR, senior dies: ethical problem or legal issue? Web.