Analyse and discuss the legal, ethical and professional issues
as applied to a chosen scenario.
The relationship between any health care professional and a patient is based on mutual self respect and understanding irrespective of culture, religion or moral values. Ethical decision-making is prominent in everyday nursing care and should always be dealt with in an appropriate manner. There are clear and concise guidelines governing correct procedures and there is a legal obligation to the patient that these are made known and every effort made to ensure that they are fully understood.
The scenario in this case is that of Samuel, aged 64 years, married and planning to move to the Caribbean. He has recently retired and the couple are looking to take a holiday there to make arrangements prior to their actual move. While in hospital for investigations, Samuel was diagnosed with bowel cancer. There is a positive prognosis if it is treated immediately. However, Samuel wants to hold back on the treatment until after his holiday. His wife disagrees and would like him to have the treatment straight away.
When a patient is being prepared for any medical procedure it is the responsibility of the health care professional to ensure that there is informed consent before any action is carried out. The consent is a two way process between the patient and the professional. There is an ethical right for every patient to have the final say in any procedures carried out on his body. This is the case when the intrusion is fairly minor through to where the actions can involve major surgery. At a basic level it can be seen as being a common courtesy. At a deeper level it will involve legal implications.
In order that the patient may be deemed to have a capacity to give informed consent, several guidelines need to be met: “
· understand, in broad terms and simple language, what the medical treatment is, its purpose and nature and why it has been proposed.
· understand its principal benefits, risks and alternatives.
· understand, in broad terms, what the consequences are of not receiving the proposed treatment.
· make a choice free from undue pressure
· retain the information long enough to make an effective decision. “
In the course of treatment it should be remembered that these guidelines may need to be reviewed at various points. A patient’s ability to fully understand different procedures may vary for a variety of reasons. It is quite possible for a patient to become very anxious at times which can make an impact on the ability to concentrate and it may impede the process. The professional should always carefully record and keep accurate documentation about any consent given – written consent by the patient is not deemed to be proof of true understanding by the patient. Every individual patient should be reassessed regularly and a good nurse will take care to adhere to the ethical and legal issues and not become complacent purely due to experience. Each case must be assesses on its own merits. Every patient must make their own decisions based on their own morals, rightly or wrongly. The patient’s decision must be respected.
Decision making on correct care is often based on the Four Principled Theory defined by Beauchamp and Childress (2001) “aims to support consideration of ethical issues in a range of healthcare settings. The four principles include respect for autonomy, benificence, non-malificence and justice. Autonomy is defined in many different contexts but in relation to healthcare it is the capacity of a rationale individual to make an informed, uncohersed decision. Respect for autonomy is about respecting the decision-making capacities of autonomous persons and allowing them to make reasoned, informed choices (Beauchamp and Childress, 2001). However, respect for patient autonomy is fraught with difficulties relating to the capacity of the patient to make sound decisions.” (JCN Online)
In the case of Samuel, consent would have to have been gained at a variety of times. The initial visit to hospital would have been carefully discussed with him detailing what his immediate medical problem was and how it would be subsequently investigated. All procedures would have been carefully explained to him and care taken to ensure that he fully understood what would be happening at each stage. When the investigations discovered bowel cancer he would have been carefully counselled on the implications of the disease, the impact on his health and also details of his subsequent treatment discussed. It is at the stage of consent to subsequent treatment that the scenario starts to raise ethical issues. Samuel does not want to have the treatment immediately as advised but would rather postpone any procedures for a period of time. As shown in the previous discussions of the patient’s right to consent, it would be unwise for the professionals to go ahead despite his opinions. His wife feels that he should have the treatment immediately but her opinion is not taken into consideration from a medical ethical capacity. In this case, careful documentation would be needed should there be any legal considerations at a later stage.
“One case law in respect of this is Case 7.4 Refusal to be ventilated.
Miss B suffered a ruptured blood vessel in her neck which damaged her spinal cord. As a consequence she was paralysed from the neck down and was on a ventilator. She was found of mind and knew that there was no cure for her condition. She asked for the ventilator to be switched off. Her doctors wished her to try some special rehabilitation to improve the standard of care and felt that an intensive care ward was not a suitable location for such a decision to be made. They were reluctant to perform such an action as switching off the ventilator with the courts approval. Miss B applied to court for a declaration to be made that the ventilator could be switched off. “ (Dimond, 2005, p.144)
It should be noted that with the case of Samuel, there would not necessarily be a terminal outcome should he decide to postpone the treatment. It was deemed preferable from a medical standpoint that timing of treatment was important.
There have been some high profile cases involving ethical and legal issues. One such case was that of Diane Pretty. Pretty was diagnosed as having motor neuron disease and over time her condition deteriorated whereby she could not communicate with anyone or move easily. She did, however, still have full mental capacities. She felt strongly that she wanted to be allowed the right to die with dignity at home with her family. This sparked off considerable debate as to the ethics of lawful euthanasia whereby her husband would help her to die – the Law stated that this was unlawful assisted suicide. Using the Human Rights Act, legal representation on behalf of Mrs Pretty presented their case to the Director of Public Prosecutions. Lawyers put forward that anyone who was involved in helping Mrs Pretty to die should be exempt from any form of prosecution. The case was turned down in both British court and also at appeal to the House of Lords. Determined to fight her case it was then taken to the European Court of Human Rights but again it was turned down.
Another case for consideration is that of Tony Bland, a Liverpool football supporter who was severely brain damaged in the Hillsborough disaster. He was 18 years old at the time of the accident and despite never regaining consciousness after the incident he was kept alive until the age of 22 years. A long court battle ensued over that time whereby the hospital, supported by his parents applied to the courts for an order to allow him to ‘die with dignity’.
In the incident Bland suffered terrible internal injuries which ultimately left him with an insufficient supply of oxgyen. This resulted in him being left in a Persistent Vegetative State (PVS).
Because Bland was unable to speak for himself, under a law that states that he was deemed incompetent, an Official Solicitor was appointed as his guardian ad litem. The Official Solicitor was necessary because if the Airedale NHS Trust went ahead and withdrew the medical care necessary to keep Bland alive, then they could be charged with his murder. Eventually, on March 3rd, 1993 after a legal ruling allowing the doctors to withdraw his treatment, Bland was able to die.
These high profile legal cases do highlight the difficult and complex ethical issues involved in patient care. The patient’s rights, values and opinions must always come first in the healthcare setting and this is only possible by adhering to strict legal and professional standards.
Dimond B (2005) Legal Aspects of Nursing (4th edition) Longman, Harlow
Dougherty, L & Lister S, (2004) Clinical Nursing Procedures (6th edition), Blackwell Publishing, Oxford.