Mrs. M is a 70-year-old Hispanic immigrant from South America who currently lives in the United States with her husband, adult daughter, and her family for about 10 years. The patient has been referred to oncology testing by her family practitioner whom she regularly sees for diabetes and hypertension. She has a 5-month history of weight loss, progressive abdominal pain, and blood in the stool. The imaging test reveals a 3-cm mass in her small intestine. The tissue diagnosis with the CT-guided needle biopsy confirms that Mrs. M has a malignant carcinoid tumor.
Before the discussion of the diagnosis, the patient’s daughter, on whom Mrs. M and her husband always rely for translation when speaking with healthcare providers, asks to speak alone with the family nurse who is to deliver the bad news. The woman requests to conceal the diagnosis from her mother, fearing that she might cope with this information poorly and that it would affect her intervention outcome negatively. The daughter wants her mother to receive the necessary treatment but would like the nurse to tell Mrs. M that it would be carried out for any other, less severe disease.
Codes of Conduct
The described ethical dilemma refers to the issue of truth-telling in terminally ill patients. As stated by Sarafis, Tsounis, Malliarou, and Lahana (2014), most of the care providers in the West are convinced that it is a basic right of patients to know the whole truth about their health condition. Nevertheless, information disclosure is approached differently in distinct countries even today (Sarafis et al., 2014). While honesty may be one of the key requirements in the US codes of professional nurse conduct, when deciding how to act in the depicted situation, an APN needs also to consider the cultural aspect defining the preferences of the patient and her family.
The American Nurses Association (ANA) Code of Ethics for Nurses may be utilized as the main reference during ethical decision-making. This code provides information about nurses’ roles, functions, and professional goals while also indicating how practitioners must communicate with patients to ensure a high level of care quality. Moreover, the ANA Code of Ethics outlines the duties that nurses hold regarding their patients, such as accountability, promotion of well-being, preservation of integrity and safety, and so forth.
It is valid to say that Provisions 1 and 2 of the ANA Code of Ethics are particularly relevant to the described ethical dilemma. They read as follows: “the nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” and “the nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population” (ANA, 2015, p. 3). These provisions imply that the APN will need to evaluate the interests of Mrs. M and her family from the patient-centered perspective, without trying to blindly impose on them the solution that she may deem to be the only right one.
Relevant Ethical Principle and Law
The ethical principle that can be violated in the depicted scenario is patient autonomy. This principle implies that each person has the right to make independent health-related decisions based on their beliefs and values (Haddad & Geiger, 2019). It also means that every person has the right “to be fully informed of their medical condition” because this right is consonant was with the abovementioned right of freedom to choose, “without undue manipulation by others” (Sarafis et al., 2014, p. 129). Thus, even though non-disclosure of diagnosis information to Mrs. M may be in her best interests, as her daughter considers, it would violate her right to know essential health information. On the other hand, the daughter’s request may be regarded as a manifestation of the patient’s will and can indeed serve to protect the best interests of Mrs. M. Therefore, the APN must decide whether to approach the patient as an independent entity and individual with needs and preferences that her relatives cannot represent or as an integral part of the family and pay respect to concerns of all its members.
Non-disclosure of diagnosis and, moreover, the administration of oncological treatment without the patient’s consent is defined by the law of torts as a form of malpractice and, thus, is illegal. For instance, in Canterbury v. Spence, 464 F2d 772, a case when a physician advised to a young man to undergo laminectomy without informing him about the risk and which consequently resulted in the patient’s paralysis, the court held that care providers must inform patients about all possible complications connected to prescribed treatment (Murray, 2012). In addition, it is legally required to tell patients why any procedure/medication is administered (Murray, 2012). In other words, the patient must be aware of the condition that will be treated and anticipated results.
Noteworthily, most of the malpractice cases are civil and may require to pay compensation to a victim (Wilson Kehoe Winingham, 2017). Sometimes practitioners’ negligence and malpractice can be viewed as criminal when it results in patient death. However, to lead to incarceration, medical malpractice should usually involve serious violation of professional standards and performance of other illegal activities, such as substance abuse, while at work.
In the introduced scenario, the only way to prevent the violation of the law and the principle of patient autonomy is by disclosing information to the patient. This decision would be in line with the deontological perspective, which implies compliance with professional duties and non-acceptance of any wrongdoing regardless of its consequences (Mandal, Ponnambath, & Parija, 2016). Even though it is not entirely clear whether this decision will upset Mrs. M or, on the contrary, relieve her, it respects her rights. Even though other family members may feel sad to have a conversation with Mrs. M about her terminal illness, the nurse can show them the benefits of keeping the information open. For instance, instead of hiding the truth from the patient, it might be better to focus on educating her about the importance of medical intervention to motivate her to engage in the process. Moreover, Mrs. M may feel more supported by her family knowing that her will is being respected. At the same time, to meet the cultural obligation of the family, it may be suggested for the daughter to convey information gradually. In this way, the practitioner will not have to compromise their professional obligations, and the family will have more opportunities to adapt.
Recommendations for a Nurse
Considering that any possible solution will likely induce some degree of harm to the parties involved, the decision-making process would cause significant moral distress to the nurse. One possible way to minimize its development and increase one’s confidence in the rightfulness of the made decision is through active communication with the family and undertaking of efforts to understand their point of view fully. Mutual communication will help to establish trust and reduce the risk of conflicts. Secondly, in difficult situations, it may be appropriate to seek advice from trusted and competent colleagues as their contribution can help to elucidate certain points in the problem that were not noticeable before. Lastly, the nurse should also seek consultation with a member of the ethics committee in her hospital as it may help to cope with distress better and allow restoring her moral resilience faster.
American Nurses Association. (2015). Code of ethics with interpretative statements. Silver Spring, MD: American Nurses Association.
Murray, B. (2012). Informed consent: What must a physician disclose to a patient? Virtual Mentor, 14(7), 563-566.
Sarafis, P., Tsounis, A., Malliarou, M., & Lahana, E. (2014). Disclosing the truth: A dilemma between instilling hope and respecting patient autonomy in everyday clinical practice. Global Journal of Health Science, 6(2), 128-137.
Mandal, J., Ponnambath, D. K., & Parija, S. C. (2016). Utilitarian and deontological ethics in medicine. Tropical Parasitology, 6(1), 5-7.
Wilson Kehoe Winingham. (2017). When medical malpractice becomes criminal. Web.