Autonomy Versus Beneficence And Non Maleficence Law Medical Essay

Published Date: 02 Nov 2017

Sarah Mohammad Iqbal Chagani

MN12009

NU 542: Ethics in Health Care

Dr Keith Cash

February 21, 2013

Pledge of Honor

I affirm that I have maintained the highest principles of honesty and integrity in my academic work and I have neither given nor received unauthorized assistance on this assignment

Introduction

Health care professionals face multiple ethical dilemmas in their daily practice including euthanasia, death with dignity, provision of treatment to terminally ill patients, declaring poor prognosis to patients and many others. Nurses are closer to patients as they are the direct caregivers and spend more time with patients; but they face multitude of ethical dilemmas requiring instant solutions and quick answers. However, ethical dilemmas have no answers; one can have alternatives but one cannot be sure whether the solutions presented are right or wrong.

Four principles of ethics, coined by Beauchamp and Childress, formulate the basis of ethical foundation in medicine and nursing. These principles assist in decision making of ethical dilemmas and also facilitate in resolving ethical conflicts. The four principles dominating ethical decision making are: respect for autonomy, beneficence, non-maleficence, and justice.

Definitions

Respect for autonomy signifies an obligation by health care professionals of respecting the decision making capabilities of the patients (Stanley, 1998). It also denotes provision of choices and alternatives to patients so that they can practice self determination (Stanley, 1998).

The principle of beneficence emphasizes on provision of benefits and good to patients (Stanley, 1998). It requires the health care professionals to weigh risks and benefits and take decisions which provide maximum benefit to the patients.

Non-maleficence deals with the provision of no harm to the patients (Stanley, 1998).

Justice deals with allocating resources equally with fairness among patients (Stanley, 1998) according to need, dessert, right and utility. It also focuses on fair distribution of resources keeping risks and benefits into consideration.

Questions

The scenario presents many ethical dilemmas for the nurse being questioned by the patient. Should the nurse declare the disease status and poor prognosis to the patient? Should the nurse lie or remain quiet as the attendants of the family know patient better than her? What would be the implications if the nurse declares the truth to the patient? What would be the result if the nurse remains quiet and moves ahead with the way things are? Is the nurse autonomous and competent enough to deal with such an ethical dilemma? Answers to these questions require an intersection of the four ethical principles and their conditions.

Autonomy versus Beneficence and Non-maleficence

Respect for autonomy means that the nurse declares the truth to the patient about her poor prognosis and ultimately bear the consequences. According to Steve Edwards, a patient has to be competent in order to practice autonomy – by competency, a patient has to be conscious and posses the understanding to absorb and grasp the information provided to take relevant decisions. Along with this, the principal also requires the health care professionals to provide complete information to the patient and not hide anything so that patients can take a holistic decision for themself. But will telling truth be helpful for the patient? It maybe! The patient after knowing the truth may want to engage in a hobby which she always wanted to do, the patient may want to fulfill a religious obligation or would want to spend some valuable time with the family, or the patient may want to go to a place where she always wanted to go, or may want to decide upon her will. The patient after knowing the truth and having complete information about herself would feel more self confident and free to take her life into her hands rather than the relatives. The patient may decide to opt for not getting any treatment and decide to die with dignity without any sufferings and pain – which is the right of all human beings. This is important because it is the patient and not the relatives who are suffering the pain; it is the patient who has to undergo the extensive, torturous treatment of the tumor and still face death but in this case a death with more pain. Additionally in many states of the world, treating patients against their right and decision is considered illegal (Stanley, 1998). Thus a thorough justification on legal ground would be required to treat patients against their knowledge and will. The principle of beneficence supports the autonomy of the patient as in this case truth telling to the patient and respecting patient autonomy could prove beneficial to the patient as she would feel more confident in deciding her course of life.

However, there is another side of the coin too. The patient may not react in the way explained above; the patient may end up in severe depression and resentment – a rift of autonomy with beneficence and non-maleficence. The latter concepts believe in weighing the benefits and risks for the patients and then taking appropriate decision for the patients. If declaring poor prognosis to the patient could harm the patient then distorting patient autonomy could be a better option. This is because, the patient is dying and by making the patient more depressed, a nurse can further elongate the suffering of the patient, thus increasing the disgrace. No doubt the patient has to die but death with dignity is the right of the patient. In this case respecting patient autonomy could not be beneficial as it can distort the benefits that the patient could acquire without knowing the reality of the disease. But is this situation really practical? If the nurse decides to distort patient autonomy as the risk of the truth outweighs the benefits then the nurse is residing towards the stigmatized principle of paternalism. The nurse in this situation assumes that the patient will benefit if the disease is not disclosed to her, but can one generalize the implications of truth to all the patients? Generalizing the findings that truth telling will definitely cause harm to patient is incorrect (Woodward, 1998) and against the code of ethics which constantly focuses on treating patients as individuals with separate identities.

Furthermore, the relatives in this scenario are asking the nurse to remain quiet about the disease to the patient; but who can judge the grounds of relatives’ requests. The request may be beneficial and maybe immoral. If the nurse decides to remain quiet and support the relatives then the paternalistic approach proves positive. The nurse is imposing her decision on the patient and if later on the patient becomes aware of the truth, then a mistrusting relationship would develop between the patient and the nurse. The patient may end up in a furious situation and die with the belief that the nurse did not tell her anything. Moreover, the nurse may also feel guilty of hiding the truth from the patient which could lead to job dissatisfaction, stress and frustration. Thus telling the truth could harm the patient and hiding it would also hurt the patient.

However, the decision to declare the truth to patient depends on the assessment of the nurse. It is the duty of the nurse to assess the cognition and emotional level of the patient to decide whether truth telling would be beneficial for the patient or distorting the autonomy would be of advantage.

Autonomy versus Justice

Additionally, the principle of justice also plays a significant role in qualifying the decision of the nurse. As explained earlier, if respecting patient autonomy and informing patient about her disease process results in the patient deciding not to go for the treatment then the justice principle can be used here. The limited resources required to treat this particular patient can be utilized in treating a patient who has a good prognosis and an increased life span. But upon knowing the disease process, if the patient still opts for the extensive treatment, then provision of the treatment becomes the duty of the health care professionals and receiving all treatment modules becomes the right of the patient. Thus it could result in misallocation of scarce resources, but again justice depends on whether a nurse respects or disrespects a patient autonomy and what decision does the patient take for herself.

Nurses’ position

In order to practice autonomy the patient needs to have complete information about her present and future perspectives; but does the nurse have enough information to dispense? In the developing world where medical dominancy rules, nurses are not considered an important pillar in the health care settings. They are counted inferior to doctors and are regarded as merely assistants to physicians, whose main task is to carry out the orders of physicians. Nurses are not expected to voice for the patient, against the doctors, as it is not believed to be the work of nurses; instead nurses in the developing world are not trained to take charge of attorneys to their patients. Thus a simple question arises, whether nurses have the freedom to practice their own autonomy? In a developing world environment, the doctors are considered as the final decision makers and no one including patients and family go against their will as they are given the position of someone next to GOD. Hence, such an environment could pose constant threats to nurses’ job securities and careers pathways. Nurses would be uncomfortable in advocating for their patients autonomy when they themselves are struggling for an improved position in the health care settings. Nurses would be reluctant to disclose the truth to this patient as they know that they do not have any managerial support backing them. The nurses would be hesitant to intervene in the paternalistic decisions of the doctors and would rather let the things remain the way they are.

No doubt, nurse could still declare the truth to the patient in the scenario but it has to be a collaborative effort of multidisciplinary teams, and all members should be capable of handling the debate which could arise after the disease is disclosed. In this scenario if the nurse decides to promote patient respect for autonomy then she would play the role of the convincing body and bring the patient, relatives and other medical staff on a unified platform for disclosure of disease to the patient.

Conclusion

Declaring the truth to the patient is the work of all health care professionals; acquiring information about the disease process is the crucial right of all patients – but declaration of truth is not simple. The four principles of autonomy, beneficence, non-maleficence and justice continuously tussle around the scenario proving each other wrong. If patient autonomy is respected then it could prove beneficial or detrimental for the patient. If the patient autonomy is respected then either it could lead in misallocation or a fair distribution of the scarce resources. Arriving to a solution is difficult; hence this scenario can have multiple alternatives but no permanent resolution.