Legal and Ethical Parameters in Nursing

Discuss about the Legal and Ethical Parameters in Nursing.

In the given scenario related to the refusal of a Jehova’s witness to take blood transfusion, the ethical dilemma which exists is whether the autonomy of the patient should be respected and the standards of care compromised or the patient’s wishes are ignored and attempt is made for saving his life. In this case an ethical dilemma has been presented, a case if and when arises an choice has to be made between the alternatives that are mutually exclusive (Beauchamp &. Walters, 2003). The ethical dilemma which is prominent in this case is that if the religious belief and autonomy of the patient is honored, the interdisciplinary team and the physicians would be faced with their moral duty of administering professional care as per the standards that are established would be compromised (Watts, 1988).

There are various ethical issues in the area of medicine which are raised due to refusal for consenting to treatment. The relavent ethical principles (Ashcroft, 2007) that are involved are the principle of the sanctity of life on one hand, the consideration towards the life quality on the other, the resource scarcity and the extent up to which the practitioners of medicine, in this situation the nurse, should go ahead and perform the requisite treatment despite there a refusal to do the same. For understanding the process of decision making in cases like that of Mark the ethical principles that are required to be considered are that of beneficence, autonomy, justice, normaleficence, compassion, justice, respecting the religious belief of the patient and how this belief has influenced the decision that has been made. It was confirmed by Gardiner (2003) that there is a huge influence of the principles mentioned above towards the choice that a person makes.

There is a conflict between the sanctity of life and the consideration towards the life quality. There exists a conflict between the treatment of a patient according the manner in which he wishes to be treated and the moral duty of utilizing the resources that are finite efficiently (Finfer, Howell, Miller, Willett, & Wilson-MacDonald, 1994). The self-determination right relates to the kind of treatment which a person chooses and not to the usage of the overall treatment.  In the case of Re C (Refusal by Adult of Medical Treatment) ([1994] 1 All ER 819), it had been stated by the Court of Appeal that it cannot be dictated by a court that a certain treatment is to be received by the patient when the same is in contradiction with the clinical judgment, mostly since an order like this does not take into account adequately, whether there were resources that were sufficient with the health authority for treating the patient or various other patients who would have benefitted probably more from the usage of such resources that are scarce (Brooks, 2012) (Re C (Refusal by Adult of Medical Treatment), 1994) (Brooks, 2012). This principle of self determination is an important ethical that has to be taken into account whose roots also lie in the legal principle of self determination.

The legal principle which is involved in the given case is that of autonomy, that through informed consent has been expressed which is a value that is fundamental in bioethics (Convention for the protection of human rights and dignity of the human being with regard to the application of biology and medicine, 1998). There is an express inclusion of the principal of self-determination in various documents of authority which includes the Europe’s Convention on Human Rights and Biomedicine under Article 7 which states that in the field of health an intervention may be carried out only after there has been an informed and free consent given by the person concerned to it (Jonsen, Veatch, & Walters, 1998).

The principles of “competence” and “capacity” are interchangeable legally. The adults are presumed, at common law, to be competent unless there is proof of their being a lack of their competence (Stewart, Kerridge, & Parker, 2007). In common law the test of competence is functional, meaning that, whether the individual has the ability of making the decision rather than basing it on the reasonableness and on criteria (Stewart & Biegler, 2016). It is required generally by law that the patient is able to retain and understand the information relating to the treatment, weigh the information, believe the information and then reach upon decision which is then communicated to the medical practitioner (Stewart, Kerridge, & Parker, 2007). In the case of Mark, the principle of competence and self-determination would be applicable. There might be a need to be admitted to intensive care due to the refusal of blood transfusions and requirement of expensive treatment which would be additional (Finfer, Howell, Miller, Willett, & Wilson-MacDonald, 1994). In an article discussed by doctors of two men who had been injured severely in a car accident but were conscious persisted that due to religious reasons they will not accept blood transfusions (Finfer, Howell, Miller, Willett, & Wilson-MacDonald, 1994). The wishes of the patients were respected and alternative treatment was resorted to. One of the patients recovered well however, the other died due to cardiac arrest. This is one of the possible outcomes that the nurse could resort to, as there is an obligation for respecting the religious objections and in the process denying the resources that are scarce to the other patients.

When the patients refuses blood transfusions there is a chance of preventable and immediate harm, the same commitment which is offered to heavy drinkers and smoker, who have resulted in health care that is expensive in later years due to their ignoring of the medical advice, cannot be denied to them (Finfer, Howell, Miller, Willett, & Wilson-MacDonald, 1994).  In the view of Finfer, until it is decided by the society as to the proportion of the resources that are to be spent on health care and the limit within which the same is to be spent and what it needs to be spent on there must be a freedom for the patients to refuse any treatment which is not acceptable to the without fearing that care would be denied to them (Finfer, Howell, Miller, Willett, & Wilson-MacDonald, 1994).  Thus, the nurse is to ensure that alternative care should be provided without compromising the religious belief of the patient. This is one of the possible options available to her with a more favorable outcome of ensuring treatment without offending the patient’s religious, since the request have been made by the patient in his complete lucid state.

It is to be understood that when there is a refusal of blood transfusion by an adult who is competent, as in this case Mark made his request for no blood transfusion while he was completely conscious and objective and has further signed a refusal of treatment form, indicating that he was fully aware of his actions. In such cases the courts would not be dictated by its view of what in the person’s best interest, what has to be looked at is the refusal’s validity which would be in terms of the patient’s capacity to make such a decision for determining whether the same is to be respected. In the case of Mallette v. Shulam where an injured woman from a serious car accident had been taken to a hospital and it was discovered by the nurse that she is a Jehovah’s Witness and that under no circumstance was she to be given blood transfusion. It was further mentioned that it should not be done under situation and that she was fully aware of the consequences however, she did not object to the use of alternatives that were non-blood.

The contents of the card were informed to the doctor but he on a personal level administered to the woman the blood transfusion when an opinion was formed by him that for preserving her health and life it was necessary to replace the blood that was lost. A good recovery was made by the woman however; she sued the hospital for assault, negligence, religious discrimination and battery. The plea of battery only was accepted by the trial judge concluding that there was restriction placed validly by the care to the right of the doctor for giving the blood transfusion to the patient and that there was no basis that could exist rationally for ignoring of such restriction. Damages of $20,000 were awarded to her and the Court of Appeal of Ontario affirmed this decision of Donnelly J. Therefore it must be kept in mind that any action taken towards treatment which is not as per the consent of the patient would be actionable in court.

Pam does not have the legal right to sue the hospital in the case where the blood transfusion is not made, since the consent is a valid consent of an adult who has the capacity of giving the same and any action taken against the will of the patient would have been actionable. It is not negligence to take into account the request of the patient.

It is from the code of ethics that the nurses’ draw from for reflective upon and understanding the perspective of a person. To honor the wishes of Mark, it is upon the nurse to ensure that the services are provided in a manner which respects’ the dignity of humans and the client’s uniqueness, unrestricted by economic or social status considerations, attributes that are personal or the health problem’s nature (Code of ethics for nurses with interpretive statements, 2001). It is necessary for honoring the decision of the patient and his dignity, supportive care needs to be provided to the patient and an effort has to be made to save his life, however, at the same time it needs to be ensured that his wishes are being respected. It is necessary for the nurse to respect the wishes of the patient despite any other personal view that the nurse might have regarding the same. The nurse needs to ensure the autonomy of mark and his right of choosing what he perceives to be the best despite what the outcome is. Mark is competent adult who has made a decision that is informed. He is not unconscious and in an objective state of mind decided not to accept the blood transfusion. The patient’s autonomy needs to be respected based on the autonomy of the patient by honouring and reflecting upon his decision based on his religious beliefs and values (Volbrecht, 2002). The principle of beneficence needs to be drawn upon which is centered on the promotion of others’ well-being. In this case it is the spiritual well being of mark and not his physiological well-being. The non-maleficence principle is to be employed by not inflicting intentional harm on the patient by way of honouring his wish. Violation of the wish of the patient would be a form of harming the patient (Leonard &. Plotnikoff, 2000). The virtues of nursing of moral courage, self-reliance and compassion also contribute to this situation.

References

Ashcroft, R. (2007). Principles of health care ethics. Chichester, West Sussex, England: John Wiley & Sons.

Beauchamp, T. & Childress, J. (2003). Principles of biomedical ethics. New York, N.Y.: Oxford University Press.

Brooks, J. (2012). Management of acutely bleeding patients who refuse blood transfusion. ISBT Science Series, 7(1), 29-33. http://dx.doi.org/10.1111/j.1751-2824.2012.01556.x

Code of ethics for nurses with interpretive statements. (2001). Washington, D.C.

Competent Adult Patient: Right to Refuse Life-Sustaining Treatment. (2002). Medical Law Review,10(2), 201-204. http://dx.doi.org/10.1093/medlaw/10.2.201

Convention for the protection of human rights and dignity of the human being with regard to the application of biology and medicine. (1998). Strasbourg.

Finfer, S., Howell, S., Miller, J., Willett, K., & Wilson-MacDonald, J. (1994). Managing patients who refuse blood transfusions: an ethical dilemma: Major trauma in two patients refusing blood transfusion. BMJ, 308(6941), 1423-26. http://dx.doi.org/10.1136/bmj.308.6941.1423

Jonsen, A., Veatch, R., & Walters, L. (1998). Source book in bioethics. Washington, D.C.: Georgetown University Press.

Leonard, B. & Plotnikoff, G. (2000). Awareness: The Heart of Cultural Competence. AACN Clinical Issues: Advanced Practice In Acute & Critical Care, 11(1), 51-59. http://dx.doi.org/10.1097/00044067-200002000-00007

Re C (Refusal by Adult of Medical Treatment), 1 All ER 819 (1994).

Rozovsky, F. (2007). Consent to treatment. Austin: Aspen Publishers/Walters Kluwer, Law & Business.

Stewart, C. & Biegler, P. (2016). A primer on the law of competence to refuse medical treatment. Aust Law J, 325-342.

Stewart, C., Kerridge, I., & Parker, M. (2007). The Australian medico-legal handbook. Marrickville, N.S.W.: Elsevier Australia.

Volbrecht, R. (2002). Nursing ethics. Upper Saddle River, N.J.: Prentice Hall.

Watts, T. (1988). Informed consent and a patient's right to refuse treatment. Monticello, Ill., USA: Vance Bibliographies.

Wicks, E. (2001). The Right to Refuse Medical Treatment under the European Convention on Human Rights. Medical Law Review, 9(1), 17-40. http://dx.doi.org/10.1093/medlaw/9.1.17