ETHICAL AND MORAL ISSUES IN HEALTH CARE.

By Reason Chivaka: MBA, BSc, BA (Hons), HE Dip, Exe Dip, RGN, ACIPD, MCIM

Introduction The need to adhere to the principles of consent and confidentiality can present challenges to health care professionals. These challenges vary from professional, moral, ethical and legal challenges and at times they present dilemmas that are difficult to resolve.

A good example is that of, Mr P a 65 years old man who is admitted into hospital for planned surgical procedure. He lives alone after having lost his wife five years ago and his only daughter M lives abroad. Since his admission, his daughter phones everyday enquiring about his condition and also requesting to speak to the patient who unfortunately could not speak to her because of his condition.

Four days post operative, his condition started to deteriorate but he requested that both medical staff and nursing staff should not tell his daughter about his worsening condition. His main reason was that, his daughter was far away and he did not want her to be worried and stressed, hence no information was given to his daughter as per his request. However, when his condition deteriorated further and the medical staff were considering was to take him back to theatre, staff in the ward queried whether it was professionally and morally right to uphold the patient's request. The argument 1

was that, as the only next of keen, the daughter should be told about the his father's condition. Consequently the staff were no longer comfortable to persist telling his daughter that, his condition was fine when in actual fact he was deteriorating. The Registrar approached the patient about the issue but he was still adamant that his daughter should not know. By the time he eventually agreed his condition had worsened such that after theatre he ended up in up in higher dependence unit (HDU) for three days before being transferred back to the ward.

When the daughter was finally told, she was shocked and when she saw him was really distressed. Although the patient eventually recovered well and was discharged after three weeks, the incident left health care staff feeling really bad.

Thoughts, Feelings and Concerns

During such incidences, health care staff particularly nurses feel very guilt about withholding information from patient's next of keen. The main worry is whether hiding information from the next of kin is morally, ethically and professionally right. Whilst the patient's choices should be respected, the main question is what will the next of kin think about health care professionals they eventually find out the patient's real condition. Although it was understandable that in the case of Mr P, he did not want his daughter to be stressed, health care professionals usually feel uncomfortable and burdened by such incidences. 2

Issues raised by the Incident and Impact on Practice and Professional Development. Whilst such incidences usually result in most health care professionals feeling uncomfortable, burdened and guilty, they have significant effect on professional practice. Mr P's case provides an insight into the challenges faced by health care professionals everyday and the difficulties of decision making when dealing with professional, moral, ethical and legal issues.

The incident raised some professional, moral and ethical issues regarding the patient's right to consent, participation in decision making, confidentiality and need for the health care professionals to be honesty and trustworthy. Patient's rights are composed of a mixture of civil, legal and moral rights. Johnstone (2006) said that, the issue of patient rights has received considerable attention such that, there has been significant policies and laws regarding patient's rights. All these endeavours are meant to prevent the violation of the rights of the patient and to ensure that their choices are properly respected and protected. However it remains debatable as to what sort of rights can patients meaningful and reasonably claim in certain contexts. Patient's rights vary from the right receive informed consent, the right to participate in decision making, the right to confidentiality and to be treated with respect. Burnard and Chapman (2005) argued that, it is very difficult for health care professionals to make decisions in cases where the patient's rights compete and conflict with the professional, ethical and moral obligations of nursing staff. The major challenge in this incident was trying 3

to balance the rights of the patient with his professional, ethical and moral and legal obligations.

Theoretical Underpinnings

Professional Issues Health care professionals, for example nurses are expected to work in accordance with the strict standards of their professional conduct. In the UK, the NMC Code of Professional Conduct governs the way nurses conduct themselves at work. The NCM Code of Professional Conduct (2008) states that, nurses should respect their patients and treat them with dignity, respect patient's confidentiality, collaborate with patient's in their care and ensure that they gain consent before treatment. The idea is that, there should be trust between the nurse and the patient. Patients should feel safe and should trust the nurse with their health and well being. Other important documents that have an impact on professional issues are the code of ethics and competency.

The codes make it abundantly clear that, when practising, nurses must uphold the highest standard of ethics and should be role models of excellent behaviour (Johnstone:2006). The vulnerability of the patient's under the care of nurses is one of the fundamental reasons behind this level of expectation. The vulnerability of the patient's should be minimised by ensuring that nurses conform to the highest ethical and professional standards. Benjamin and Curtis (1992) defines code of professional 4

standards and ethics as a document that stipulates professional and moral rules or expectations whose purpose is to guide professional conduct. Whilst the code of professional conduct is meant to guide nurses at work, in practice, there are many challenges that are faced by nurses. For example the code of professional conduct states that, nurses must maintain patient's confidentiality, respect patients, preferences and decisions, yet when faced with situations where a vulnerable patient is being abused by carers or relatives, it is difficult to do so.

The NMC Code of Conduct (2008) states that, nurses must be advocates for their patients. In practice the issues of being patient advocates causes both professional and moral dilemmas. When dealing with situations where a vulnerable patient is being abused by carers or relatives, trying to uphold the interest of the patient, means those of the carers are violated. By not telling the next of kin the truth as requested by the patient means that, the nurse will be upholding the patient's right to information sharing and decision making but may also be violating their own code of professional conduct which states that, nurses should conduct themselves in an honesty and truthful manner. In such a situation, how will nurses justify their conduct of not telling the carers or relatives the truth. These examples show that, nurses are always faced with professionals, ethical and moral issues and dilemmas that impact on decision making. The question is should health care professional be guided by their professional code of conduct only or they should also consider moral issues. 5

Moral Issues The nature of the work nurses do, present challenges in terms of decision making when confronted with problems that causes moral dilemmas. The main questions that most nurses will be asking themselves are, how to deal with a given situation, what is the best course of action, how to know the whether the decision is morally right and whether the behaviour is ethically correct.

The answers to the above questions are not straight forward as the way one would answer them is influenced by one's beliefs, values, life experience, professional knowledge and experience (Johnstone:2006). However, there is an argument that such situations requires a systematic approach, experience and consideration should be given to all the issues at stake in order to find a way of how best to resolve them. According to Little (2001), the problem with moral issues is that there is no universal consensus on what should be considered right or wrong and moral beliefs can be misguided resulting in mistaken moral judgements. The best way to deal with moral decisions is to provide good reasons for decision and actions taken.

Beauchamp and Childress (2001) argued that, justification of moral decisions should be supported by strong moral reasons. Various theories guide professionals in dealing with moral problems. Moral theories present the means for assessing the moral values of actions and they help nurses to deal with incidents that present moral dilemmas (Melia:2004). The major ethical theories that are used to deal with moral challenges 6

are deontological which states that, regardless of the results, duty is the basis of all moral actions (Fry and Johnstone:2008). On the contrary, teleology states that, the results should be the only basis for judging the actions of moral actions (Rumbold:2005). The principle of autonomy emphasises the patient's ability to make independent decision, whilst that of beneficence states that, nurses should work for the benefit of their patients ( Thompson et al:2003). Whilst these and other theories differ on how to deal with moral dilemmas, they agree on the fact that the competence of individuals in making their choices is vital.

Moral theories are important because they help people to describe, understand their world and devise moral standards that provides them with frameworks in determining what is acceptable actions and what is not. Burnard and Chapman (2005) argued that evaluation of moral judgements, decisions and reflection is only possible with moral theoretical underpinnings. In practice moral theories help nurses to deal with situations that present moral dilemmas that makes decision making very difficult.

Withholding information to carers and relatives at the request of the patient, presents moral dilemmas to nurses as it is morally wrong to tell relatives that the patient is fine when knowing very well that the condition is deteriorating. Whilst it is in accordance with the NMC Professional code of Conduct (2008) to respect patient right to decision making and information sharing, it is morally wrong not to tell the truth to family members especially those who may be abroad and are not able to visit the 7

patient. The morality of any decision made is questioned on the basis of its moral worthiness and consequences and how that affected the people involved.

Legal Issues Legal issues affect nurses in their everyday work as evidenced by the ever increasing ligations against the National Health Services (NHS) due to clinical errors, wrong decisions and other issues. Aiken (2009) said, law is the foundation of statutes, rules and regulations that govern people, health and safety and welfares as well as relationships and behaviour and interactions with society.

The law is important in nursing because what is considered professionally, morally or ethically right may be interpreted as illegal by the law. According to Fry and Johnstone (2008), what may be ethically right may be legally incorrect and vice versa. The case of euthanasia is a classic example of how the law clashes with professional and moral values. Whilst the argument is that, it is morally right to help people who are in persistent and severe pain who decide to die, the law states that it is illegal to do so and such actions are considered as murder (Pozgar et al: 2009). Therefore the question is, do patients have the right to make autonomous decisions and are nurses able to exercise their advocacy roles without having to thinking about the legal consequences?. The answers is that, the law is supreme in whatever we do and nurses should abide by the law and should be very careful as the law is a different guiding system to professional, moral and ethical guidelines. 8

In nursing legally defensive decision making is the norm. Even though a nurse may feel that it is professionally, morally and ethically right to do something, it is the legal consideration that guides the action to be taken (Kluwer:2008). This means that, a nurse may refuse to do something just because doing so is considered illegal, hence such a decision is guided by legal rather than moral or clinical decision. It is therefore vital to highlight that, most decisions taken by nurses are influenced by considerations of legal consequences rather than clinical or moral consequences of complying with the request of the patient. The challenge for nurses is how to deal with dilemmas emanating from the conflict between professional, moral, ethical and legal issues.

Discussion of Actions taken (Personal and Professional Values) The first issue raised by this incident was the patient's right to make autonomous decisions and the right make choices especially on information sharing. The other issues were the patient's rights to consent, confidentiality and the need for nurses to be honesty and trustworthy.

The NMC Code of Professional Conduct (2008) states that, nurses should respect and uphold the patient's rights to make autonomous decisions and that the nurses must be honesty and trustworthy. The patient in question was competent to make his own decisions regarding his care hence health care professional were expected to respect and uphold his decision as required by the professional code of conduct. Respecting 9

and upholding the patient's decisions entailed not telling his daughter his actual condition. According to Wallace (1991) confidentiality means not disclosing any information relating to a patient except with their consent, when required by law or to alleviate a serious threat to life and health. The principle of confidentiality has historically been interpreted as an absolute principle, meaning that at times disclosure of information is not permitted even if the outcome of doing so is good.

During an incident similar to this one, the actions of health care professionals are guided by the principle of confidentiality. Consequently no information pertaining to the patient's deteriorating condition will be given to the next of kin. Childress (2001) argued that, the justification of the supremacy of the confidentiality principle in health care practice is due to the need to preserve the trust between the health care professional and the patient. Looking at this incident, it was clear that, the patient relied on health care professionals to keep his condition confidential from the daughter. An attempt to violate that trust by disclosing his condition without his consent was going to destroy the trust and the relationship between the patient and healthcare professionals. The principles of consent and confidentiality are fundamental as they guide actions in health care professional- client relationship (Pozgar et al: 2009). The other fundamental reason why these principles are important is because they are recognised in law.

Health care professionals found themselves in a dilemma as whilst it is legally right 10

to respect and uphold the patient's rights to consent and confidentiality, on the contrary, there is a strong feeling that, it is morally and ethically wrong to hide information pertaining to the patient condition to the next of kin. Withholding the correct information to the next of kin just because the patient requested so, presents professional, moral ethical and even legal dilemmas to health care professionals. Pozgar et al (2009) said that, moral dilemmas arise when values, duties, rights and consequences of an action conflict. The NMC Code of Professional Conduct (2008) states that, nurses should uphold patient's rights to consent and confidentiality. It also states that, nurses should be trustworthy and honesty, meaning that, they should tell the truth. In incidences like this, it is difficult for health care professionals to reconcile these two conflicting provisions of the code of professional conduct.

Withholding the information from the next of kin as requested by patients is right because it means their rights to consent and confidentiality are respected and upheld. On the contrary, persistently giving incorrect information tot the next of kin is a violation of the professional code of conduct which states that, nurses should be honesty, trustworthy and should always tell the truth. Most healthcare professionals feel that doing is professionally, morally and ethically wrong. However, they also feel that, violating the patient's rights to consent and confidentiality could have severe legal consequences. On the contrary if something is to happen to the patient and then next get to know the truth, healthcare professionals will end up being sued. 11

Since the law is supreme, discussions among health care professionals is usually centred on the legal consequences of not upholding the patient's rights to consent, confidentiality and legal consequences of withholding information from the patient's next of kin. In health care, decisions are made on the basis of what is required or prohibited by the law (Johnstone:2006). The guiding principle in decision making by health care professionals is based on doing actions that do not result in legal actions and accompanying costs of failure to comply (Kluwer:2008). With this in mind most healthcare professionals will resolve such dilemmas by discussing with the patient for them to consent to the release of information regarding their conditions.

Conclusion Problem solving is not easy for healthcare professionals because the rights of the patients to consent, confidentiality and the legal consequences usually out weigh the professional, moral and ethical issues. Violating patients right by releasing information to the next of kin without their consent will usually destroy the trust between patients and health care professionals. On the extreme end, violating these rights could lead to legal action that could be costly. The NMC code of Professional conduct (2008) makes it very clear that, failure to comply with the provisions of the code could bring the fitness to practice of a nurse into question and endanger the nurse's registration. Whilst feeling morally and ethically guilty the only way

healthcare professionals resolve such dilemmas is by persistently asking the patient to reconsider their decisions. 12

This is in consideration of the fact that, in such incidences, moral and ethical issues are subordinate to legal and professional considerations. Kluwer (2008) argued that, even though a nurse may feel that it is professionally, morally and ethically right to do something, it is the legal consideration that guides the action to be taken. The truth is that moral judgement, which involves being able to choose an option from among choices is very difficult to exercise in nursing (Pozgar et al: 2009). However, whilst moral and at times professional issues are subordinate to legal issues, they are important as they help in deciding the course of action to take. Kopelman (1995) advised that, when faced with a moral dilemma healthcare professionals should not only rely on personal experience and preferences but to look elsewhere to strengthen our moral choices and actions.

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