All civilization has faced health challenges from ancient times to the present. In traditional practice, ethicist usually used casuistry case-based approach as a method of analysis for centuries in Jewish medical ethics. Therapeutic paternalism assumed as usual practice by most health care pros and their patient’s believed that whatever done by health care team will be better for them. Hence, the queries of medical ethics have been argued since the early development of Western medicine. “Ethics is a philosophical approach that covers entire associations of belongings and involved with good and bad, moral duty, obligations and values” (Lindberg, J.B. et al 1994). Potter and Perry, (2010) present that it is a human fundamental right and moral decisions in health care should be practiced by four principles. Beauchamp and Childress addressed the four moral and health care principles.
Scenario: “a nurse is an assigned to a patient who has been diagnosed with an inoperable tumor and is terminally ill. The medical staff and the family insist that she is not to be told about her prognosis. She keeps asking the nurse, “Am I dying”. What should the nurse do in this situation?”
Consideration of the ethical issue using the Four Principles framework
Respect for autonomy: Respect for patient autonomy. It means that the patients have the rights to decide, which track of action good for them. The notion of autonomy is a basis and keystone of nursing practice as a due respect for patient. Autonomy concept is nothing. Miss Y may not be independent and not legally competent to respect for autonomy, but this does not mean that ethically her views should not be considered and respected as far as possible. She has spoken her wish clearly; she wants to know about her condition.
Beneficence: The ethics of beneficence such as ethical behavior is obliged to do well.
The benefits of acting beneficently would need to be weighed against the dis-benefits of failing to respect Miss Y’s autonomy. (From a legal point of view the wishes of a competent patient cannot be override in her best interests).
Non maleficence: the moral obligation to do no harm is familiar within both medical and nursing practice. Here, Miss Y would be harmed by telling about her end stage of disease. Which course of action would result in the greatest harm?
Justice: the principle of justice suggests that ethical behavior is a manner that treats people fairly (“Ethical issues,” 2001).
Moreover in the context of Pakistani system, Pakistan Nursing Council (PNC) offered the professional code of ethics with job description for registered nurses. It gives direction for decision-making regarding ethical matters and serves for self-evaluation and reflection regarding ethical nursing practice.
Compare and contrast between four ethical principles
Nurses are ethically compelled to deliver safe and sound, experienced and moral care to all patients. These main beliefs give us understanding about the nature of obligations associated with these principles. (Proof) Beauchamp and Childress explain that ethics leads us to proceedings, but we still need to judge a condition and express a suitable response. This judgment and response learn from training as much as from moralities (Limentani, 1999).
According to given scenario, as patient is in critical condition with diagnosed case of cancer and in the stage of terminally ill. Nurse might not decide either she should gave the answer or not. In this critical condition, may answer create emotional tragic situation to the patient and may patient ailment become more deteriorate due to emotional disturbance or in this situation therapeutic freedom seems sensible. Moreover, the notion of ethical application in serious condition is the balance between respect for autonomy of the patient and wish to do in a beneficent attitude may results in dissimilarity and tension (Campbell 1994).
This type of moral dilemmas arise due to clashes between moral principles, such as truth telling decisions, autonomy, obligations of beneficence and non-maleficence. These three ethical codes can build conflict with the principle of justice. Mostly two types of issues arise from nursing practice. There is a conflict between obligations to respect of autonomy and obligations of beneficence and non-maleficence. In reality, there are many other types of situations in which this type of conflict occurs, such as feeding, giving medication to a patient against their wishes, and trying to prevent a patient from committing suicide etc. It is remarkable that conflicts happen in health care institutions across the country on a daily basis. Although most health care professionals are now qualified communication skills, they are not taught the compromise and conciliation needed to deal with severe disagreements.
One drawback of the “Four Principles” approach is that when different persons involved in an ethical decision might differ about the virtual weight to each code. For example in a given scenario, a patient who wants to know about their critical condition and asking you “Am I dying?” This might be arguing that the principle of autonomy should be uppermost, while the other clinical staff may maintain beneficence and non-maleficence on top priority. The health care principles do not portray and point out a hierarchical ordering by them. In this example, if patient need spiritual and religious support and nurse decides to tell them reality in the favor of respect of autonomy, they will lose the role of paternalism. In this way, autonomy will be high weighed and patient may be getting a golden chance to do pray for forgiveness from Allah. If they do not tell the real situation to the patient and keep a paramount of beneficence and mal-eficence then paternalism will be weighed but patient might be so far to pray and some special religious practice. Actually, there will be no justice for the principle of justice. In nursing, justice often focuses on equitable access to care and fair scarce resource distribution. It is the requirement for nurses to focus on the patient’s particular care needs, vision, preferences and to acknowledge the individual’s unique practice (Wilson-Barnett 1994).
Arber and Gallagher (2004) stated that any news which is not warmly accepted is known as a bad news. Any insensitive approach increases the suffering of recipients of bad news, can exerts a long lasting impact on their ability to adapt and adjust, can lead to anger and increased risk of legal action. Furthermore, the situation becomes more complicated because some patients misinterpret messages that they hear. For breach bad news, strong communication are required which should base on both compassionate and kind attitude.
Not to telling a truth, is an essential skill for health care provider because many of them find it challenging to communicate bad information, especially when involves a life-threatening situation. Some feel untrained while others fear the news will be distressing and adversely affect the patient, family, or the therapeutic relationship. Some colleagues embark on a very positive approach; giving the patient and relatives artificial expectation and believing that the patient is more ideal in her ignorance. Some of them take a middle pathway and explain all the facts to the relatives while keeping the patient in the dark. Mohandas (1995) stated that, few describe at some degree about their opinion regarding patient’s prognosis, and the severity of disease, expected possibilities of treatment, adverse effects, economic burden and short and long term prognosis. In this regard they upset some patients and families. The persons involved in this situation where my patient with a cancer diagnosed lady and me (as a staff nurse). The ethical principles involved in this situation where my patient’s autonomy and veracity verses non-maleficence. The ethical dilemma confronting to me that if I (as a staff nurse) did not deliver the news then might I was not following the ethical principle of veracity and patient’s autonomy. However, if I disclose the news to the patient then I would be violating the principle of non-maleficence. Veracity (telling the truth), although distressing in the short term, but will result in more benefit than harm in the long term (Sokol, 2006). Keeping the principle of non-maleficence in my mind if I delivered the information to the patient intentionally then it would be resulted the intrinsic effect of harming the patient that violates the negative duty not to harm.
Arguments and counterarguments
The literature support that it is ethically right to tell the truth to the patient. Sokol (2006) described that not telling the truth may breach the trust of patient-nurse relationship and leads to loss of trust. Veracity, although upsetting in the short term, but will result more good than harm in the long run. The patients should have full disclosure of awful news should tell the truth if this is their wish according to the scenario. Disclosing the information prevent further argument and loss of trust if the patient later discover the truth. The Islamic point of view regarding veracity is very clear as, it was narrated that “Abd-Allaah ibn Mas’ood said: The messenger of Allah (PBUH) said: “Truthfulness is righteousness, and righteousness leads to Paradise. Lying is evildoing, and evildoing leads to Hell”. If patient is in acute condition and revealing the reality may affect adverse consequences, it would cause an excessive psychosocial or spiritual burden on patient. In this critical situation then not telling the truth is favorable for the well-being of patient (Tse et al., 2003). The therapeutic privilege provides opportunity to the physician in few conditions when expose the truth is forbidden as it resulted in actual and expectable damage in patient’s health status. It is also a fact that doctors do not have a duty to disclose the whole facts about a patient’s medical condition in respect of beneficence and maleficence.
Advantages of truth telling: Disclosure is essential to future informed consent. The patient who are not communicated about their prognosis, and kept unaware may be at risk of future misdiagnosis. Veracity promotes trust between patient and health care providers. Truthful disclosure may minimize the probability of legal liability.
Disadvantages of truth telling: Patient may misinterpret the information. The other possible harm may be patient lose the hope. Patient health is the most important issue for the health care provider, which can be affected by truth telling, and patient may go to shock. Patient may develop stress and anxiety.
Veracity (telling the truth) to the patient needs extraordinary focus, because now a day’s patients are, comparatively to earlier, more vulnerable to face serious harms if they are not completely acknowledged regarding their health status. Not only patient’s self-government destabilized, as well as patients who are not informed the actual truth about an intervention, practice a loss of truth which is mandatory for remedial process. Honesty counts to patients because they are not well exposed to the disease, and disturbed with lots of questions in their mind which require veracity. A bad news is always a bad news. But the manner in which it is conveyed can have a profound effect on both the patient and the health care provider. Breaking bad news suggested an approach which supports the health care providers to tell the truth in the critical circumstances.
Buckman (2005) suggested the S-P-I-K-E-S protocol a strategy to disclose the bad news and tell the truth by minimizing the hazardous effects of bad news. In this respect, the most important factor is setting. It includes isolation, involvement of the significant family member and kind and calm behavior. Before breaking the news, an accurate patient’s perception is necessary. It facilitates the health care providers a clue, that how patient view the meaning of the situation and calculate the facts and figure of the medical situation. What did you think something is going on with you? Such type of open ended question is helpful to understand patient’s perception. Invite the patient through indirect permission, and respect the patient’s right to know and ask for example that, how much extent you required information regarding your treatment and diagnosis? Before delivering information, provide the patient a few moments that she prepared psychologically. The last intervention is empathetic response. Empathetic approach can stabilize the patient’s emotions through acknowledge that you are feeling their emotions.
Keele (2008) described that according to Kant, veracity is a very important to learn that is categorical in nature, one should do their duty even it cause harm to others. Veracity is the medical principle which matter for the health of the patient. But in spite of all these facts according to health care system and the medical profession in our context, trust is the basic element to develop therapeutic relationship with patient. The image of health care providers would be destroying if they would not represent the real situation in front of patient. Truthful exposure of relevant information is a legal and ethical duty of medical professionals to be explored in front of patient. In this way, there is no final conclusion and nurse should do accordingly by their experience, honesty, wisdom and use the futility and theory of utilitarianism.