LEGAL
Principled decision making in district nurse practice Richard Griffith
Senior Lecturer in Health Law, College of Health Science, Swansea University
Moral dilemmas in district nursing It can be seen for purposes of the case study that situations arise in nursing practice where no clear conclusion can be
ABSTRACT
This article outlines a case study in which Sister Mary Newsome is in conflict with her district nurse colleague over the care of Margaret, 67, who they visit to monitor blood glucose levels and calculate the insulin dose to manage her diabetes. Recently, Margaret has been refusing to answer the door to the district nurses and has been eating sugary foods that have resulted in five admissions for diabetic ketoacidosis. While Sister Newsome believes continued care at home is best for Margaret, her colleague believes that only residential care will ensure Margaret maintains an appropriate diet and receives her insulin. Sister Newsome considers how best to resolve the conflict over the care of Margaret.
KEY WORDS
w Principled decisions w Morals w Ethics w Dilemmas
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immediately drawn from the district nurse’s understanding of the law or from the professional Code (NMC, 2008). In the case study, Sister Newsome’s view is that a decision to place Margaret in residential care because she is not cooperating with the district nurse team is wrong. Her fellow district nurse believes the patient’s health and welfare is best maintained in a more structured and supervised environment. Sister Newsome is now faced with a dilemma. Both her decision to want to continue treatment at home and the nurse’s desire to have Margaret placed in residential care are lawful. Neither district nurse is proposing to act unlawfully: the decision is one of morality. Morals are influenced not only by the law, but by our culture, religion, beliefs, values and experience. District nurses will find that some clinical decisions are morally acceptable to them, while others are not.
Moral issues and ethical approaches According to Thompson et al (2000), morals and ethics are terms used to refer to social customs regarding the rights and wrongs, in theory and practice, of human behaviour. ‘Moral’ refers to what a person believes is right or wrong based on their culture, experience, upbringing, education and religion. A district nurse may believe that the right to independence and family life should always be respected, and all patients should be treated at home even if they refuse to give their full cooperation. Others may believe that the independence should not be respected where it merely results in the person making unwise choices. It might be argued that it is far better to place that person in residential care to ensure their health and welfare, even if the person is unhappy there. A person’s morals are founded on their beliefs and values. Decisions made by that individual will be influenced by their beliefs and values. District nurses will have their own set of beliefs and values, and their own moral background that will influence decisions when caring for a person. However, what a district nurse considers to be right could in itself be immoral. It could be argued that the patient has a right to refuse treatment and that their autonomy should be respected. As such, a patient must not
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istrict nurses are required to practice in a way that is accepted by law and their professional Code (Nursing and Midwifery Council (NMC), 2008). However, despite positivist claims to the contrary, the law does not always provide the answer to the complex dilemmas faced by district nurses, such as the following. Sister Mary Newsome is in conflict with her district nurse colleague over the care of Margaret, 67, who they visit to monitor blood glucose levels and calculate the insulin dose to manage her diabetes. Recently, Margaret has been refusing to answer the door to the district nurses and has been eating sugary foods that have resulted in five admissions for diabetic ketoacidosis. While Sister Newsome believes continued care at home is best for Margaret, her colleague believes that only residential care will ensure Margaret maintains an appropriate diet and receives her insulin. These situations give rise to questions about whether a nursing intervention is morally acceptable and ethically right. This article will use this case study, based on Re M (Best Interests: Deprivation of Liberty) [2013], to explore the notion of morals as they apply to district nursing and consider what is meant by morals and ethics.
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LEGAL be forced to accept treatment just because others believe it is right. Such coercion may be viewed as unprofessional, unlawful and immoral. This gives rise to a moral dilemma that needs to be considered. A moral dilemma, according to Thompson et al (2000), is a choice between two equally unsatisfactory alternatives. Sister Newsome believes that Margaret is capable of making a decision to refuse treatment and that this should be respected (respect for autonomy). Her colleague believes that one must always act in a way that promotes the wellbeing of others and that should include a residential placement, even though it is not the patient’s preferred choice. This is where ethics and the application of ethical principles help district nurses to judge the rightness or wrongness of a decision. According to Edwards (2009), ethics may be described as the enquiry into moral situations and the language employed to describe them. Therefore, ethics involves the application of principles to a moral problem in order to help judge whether an action is right or wrong.
A principle-based approach to ethical decision making A common approach to the ethics of health care was developed by the Beauchamp and Childress (1989) and is based on four moral principles and attention to their application. The ‘four principles’ approach argues that whatever our personal philosophy, politics, religion, moral theory, or life stance, we will be able to commit ourselves to these four prima facie moral principles. The four principles are considered to encompass most of the moral issues that arise in health care. Prima facie means that the principle is binding unless it conflicts with another moral principle—if it does, a choice will have to be made between them. The ‘four principles’ approach does not provide a method for choosing the right answer to a moral dilemma, but it will provide a common set of moral commitments, a common moral language, and a common set of moral issues (Gillon, 1994). The four moral principles are (Beauchamp and Childress, 1989): w Respect for autonomy—respect for the right of an individual to decide for himself or herself w Non-maleficence—obligation not to harm others w Beneficence—requirement to act in ways that promote the wellbeing of others w Justice—obligation to treat others fairly.
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Autonomy The first principle, respect for autonomy, requires respect for the choice made by an individual. In a health-care context, this means that a patient has a right to decide whether or not to undergo any health-care intervention, even if the refusal will lead to harm or death. The term ‘autonomy’ is derived from the Greek meaning ‘self governing’. It refers to the capacity of an individual to make an informed and uncoerced decision about their future. Autonomy is about self-rule with no control, undue influence or interference from others. It involves respect for an individual’s choice
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based on their own values and beliefs. Gillon (1994) referred to three concepts of autonomy. Autonomy of thought involves deciding for oneself using all available information and weighing this information. Autonomy of will involves the intention to do something as a result of a decision, and autonomy of action involves doing something based on one’s own decision, such as refusing to consent to treatment (Box 1).
Beneficence and non-maleficence Gillon (1994) argues that whenever a health professional tries to help others, they inevitably risk harming them. District nurses must therefore consider the principles of beneficence and non-maleficence together with the aim of ensuring benefit to the patient over harm (see Box 2). The NMC’s Code (2008) underpins a moral and professional obligation to provide overall benefit to patients with minimal harm—that is, beneficence with non-maleficence. To achieve this, district nurses are committed to a wide range of obligations. They must ensure that they are able to deliver competent, safe care, so they need rigorous and effective education and training both before and during their professional careers. They must also ensure that nursing care is of benefit to the patient. In doing this, district nurses must respect the patient’s autonomy. What constitutes benefit for one patient may be harm for another. A mastectomy may constitute an overall benefit for one woman with breast cancer, while for another the destruction of part of her femininity may be so harmful that it cannot be outweighed by the prospect of extended life expectancy.
Justice The fourth principle is justice: that is, an obligation to treat others fairly. Justice includes the principles of fairness, equity and an entitlement to what is deserved. Gillon (1994) suggests the principle can be divided into three categories: w Fair distribution of scarce resources (distributive justice) w Respect for people’s rights (rights-based justice)
Box 1. The right to self-determination Hannah, 13, was found to have leukaemia at the age of 4. After chemotherapy treatment she was diagnosed with a heart-muscle disease called cardiomyopathy: a hole in her heart caused by a high-strength drug she had been given to fight an infection. She then needed a heart transplant but turned it down to return home to die in the company of her parents and siblings because she did not feel she could tolerate more hospital time. Hannah’s wish to go home was, at first, overridden by the medical authorities but she was later allowed to return home. Eight months later she changed her mind and asked to be put back on the transplant list after she suffered partial kidney failure shortly after her 14th birthday. Source: Retter (2013)
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LEGAL
Box 2. Beneficence conflicting with non-maleficence A nurse was so concerned about poor care in the nursing home where she worked that she agreed to participate in a television documentary. The nurse secretly filmed the neglect of elderly patients. She was hailed a hero for her actions by patient groups and fellow nurses and received awards for bringing her concerns to the public’s attention. However, the Nursing and Midwifery Council took a dim view of her actions as the filming was without the consent of her patients and was a breach of confidentiality. She was initially struck off the nursing register for misconduct in April 2009 after admitting breaching patient confidentiality, but said she had agreed to film at the hospital to highlight terrible conditions there. Following a public outcry and threat of court action, the striking-off order was replaced by a one-year caution. Source: Plunkett (2009)
Box 3. Justice for all A hospital spent £20 000 creating a private ward to provide dialysis treatment to a patient, a convicted rapist, who had conducted a reign of terror at a hospital where he received life-saving dialysis treatment three times a week. The hospital had to take out a court order barring him from attacking staff, and it spends £18 000 a year to pay for security guards to escort him during his visits. It pays a further £2000 annually for taxis to take him to and from the hospital to ensure he does not loiter around the building. This is because the hospital felt his human rights would be violated if they refused to treat him. Source: Dickson (2006)
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a patient’s lifestyle will not provide a morally defensible justification for refusing to care for a person with HIV. The principle of justice also requires nurses to obey morally acceptable laws. Even though a nurse may disapprove of the law, they are morally obliged to obey it (Box 3).
Applying the four principles Applying the four principles allows Sister Newsome to come to an ethical decision regarding the future care of Margaret.
Respect for autonomy The principle of respect for autonomy entails taking into account and giving consideration to the patient’s views on treatment. Autonomy is not an all-or-nothing concept. Margaret may not have capacity to decide on accommodation for care and treatment, but this does not mean that her views should not be considered and respected as far as possible. She has expressed her wishes clearly; she does not wish to move away from home. She would be miserable in residential care away from her friends and loved ones. An autonomous decision does not have to be the correct decision, otherwise individual needs and values would not be respected. However, an autonomous decision is one that is informed. Questions to consider are as follows: w Has Margaret been given information about the consequences of the benefits and risks of living at home and cooperating with her insulin management in a manner that she can understand? w Has she been supported to weigh values and belief against the consequences of having or refusing treatment for her diabetes?
Beneficence District nurses must act to benefit their patients. This principle may clash with the principle of autonomy when the patient makes a decision that the nurse does not think will benefit the patient i.e., it is not in their best interests. District nurses must consider both the long-term and short-term effects of overriding Margaret’s views. In the short term, Margaret will be frightened and upset to have to leave her home and move to residential care. This may lead her to distrust health professionals in the future and to be reluctant to seek help. In the long term, there will be a benefit to Margaret in having her autonomy overridden on this occasion. Without treatment, her health will deteriorate. The benefits of acting in Margaret’s best interests would need to be weighed against the disbenefits of failing to respect her autonomy.
Non-maleficence The principle of non-maleficence involves doing no harm to the patient. Margaret would be harmed by moving her to residential care against her wishes. She says she will be miserable there and would rather be dead than in residential care. However, if she continues to suffer diabetic ketoacidosis, her health and wellbeing will suffer.
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w Respect for morally acceptable laws (legal justice). Equality is at the heart of justice. It is important to treat equals equally and to treat unequals unequally in proportion to the inequalities. In the context of the allocation of resources, conflicts exist between moral concerns such as the need: w To provide sufficient health care to meet the needs of all who need it w When this is not possible, to distribute health care resources in proportion to need for health care w To allow nurses to give priority to the needs of their patients w To provide equal access to health care for all w To allow people as much choice as possible in selecting their health care w To maximise the benefit produced by the available resources w To respect the autonomy of those who provide resources by limiting the cost to taxpayers. All these criteria for allocating health-care resources can be morally justified, but not all can be fully met simultaneously. Rights-based justice requires respect for patients’ rights. District nurses have no special privilege as health workers to create rights for patients or decide which rights should apply. For example, a district nurse’s disapproval of
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LEGAL Assessing which course of action would result in the greatest harm relies on assumptions regarding how successful placement in residential care is likely to be and how likely it is that Margaret will be willing and able to cooperate with her treatment at home.
Justice It would be relevant to consider the cost effectiveness of the care and treatment options for Margaret. Decisions cannot be made on purely economic grounds and the district nurse must show that any decision is not discriminatory in accordance with the Equality Act 2010 (UK Government, 2010).
Magnetic importance The principle approach to resolving dilemmas does not give priority to one principle over another, and there may be a need to choose where a conflict occurs (Edwards, 2009). In ITW v Z [2009] the Court gave guidance with regard to balancing the different considerations in relation to applying the four principles in each case.The Court held that the weight to be attached to the principles would differ depending upon the individual circumstances of the particular case. A feature or factor in relation to the principles that in one case may carry great weight may, in another, superficially similar case, carry much less, or even very little, weight. In most cases there are one or more features that are of what the Court calls ‘magnetic importance’ and they will greatly influence or even determine the outcome. In our case study, Margaret’s wish to stay at home and her view that she would be miserable to the point of taking her own life if she were to go to residential care is likely to be of magnetic importance and strongly influence Sister Newsome’s decision making.
Conclusion Despite the increase in health-care legislation as a result of the Human Rights Act 1998 (UK Government, 1998), many situations in district nursing practice give rise to questions that the law cannot resolve, as they call into question whether such practice is morally acceptable and ethically right. ‘Moral’ refers to what we believe is right or wrong, and this is based on our culture, experience, upbringing, education and religion. ‘Ethics’ refers to the application of certain
tation, high quality mentoring s. The book describes a number and the many ways it can be ence, the claims that reflection can nce, safe and accountable practice, and the collective improvement of e. Each principle is illustrated with ed within the professional literature.
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ISBN 1-85642-391-3
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Reflection: Principles and Practices for
HEALTHCARE PROFESSIONALS
If you are interested in finding out more about the legal cases noted in this feature, please email the editor at [email protected] ITW v Z [2009] EWHC 2525 (Fam) Re M (Best Interests: Deprivation of Liberty) [2013] EWHC 3456 (COP) Beauchamp T, Childress J (1989) Principles of Biomedical Ethics. Oxford University Press, Oxford Dickson N (2006) Attacker given own ward BBC News, 25 April. http://tinyurl. com/nyqmsg6 (accessed 22 September 2014) Edwards S (1999) Nursing Ethics: A Principle-based Approach. Palgrave, London Gillon R (1994) Medical ethics: four principles plus attention to scope. BMJ 309(6948): 184–8 Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. NMC, London. http://tinyurl. com/mz8nb8w (accessed 22 September 2014) Plunkett J (2009) Nurse who secretly filmed for Panorama is struck off register. The Guardian, 16 April. http://tinyurl.com/mrztpkr (accessed 22 September 2014) Retter E (2013) Hannah Jones at 18: I turned down heart transplant aged 13 but I’m so glad I changed my mind. Mirror, July 13. http://tinyurl.com/nwy94h4 (accessed 22 September 2014) Thompson I, Melia K, Boyd K (2000) Nursing Ethics. Churchill Livingstone, London UK Government (1998) Human Rights Act 1998. http://tinyurl.com/prua46k (accessed 22 September 2014) UK Government (2010) Equality Act 2010. http://tinyurl.com/pcane6w (accessed 22 September 2014)
KEY POINTS
w Many situations in district nursing practice cannot be resolved by the law as they give rise to questions about whether such practice is morally acceptable and ethically right w The application of ethical principles to a moral problem will enable district nurses to judge whether an action is right or wrong w When considering a moral dilemma, each principle must be taken into account unless one conflicts with another w Where there is a conflict between principles, there is generally a factor that carries greater weight, or ‘magnetic importance’, on which the decision can be based
New Edition of Bestselling Series on Reflective Practice Reflection: Principles and Practices for Healthcare Professionals 2nd edition New chapters on ‘appreciative reflection’ and the value of reflection for continuing professional development This an essential guide for all healthcare professionals to learn about their strengths, how to develop and use them. Discusses the need for skilful facilitation, high quality mentoring and the necessity for good support networks. Presents key principles and practices of reflection and the many ways it can be facilitated. It attempts to support, with evidence, the claims that reflection can be a catalyst for enhancing clinical competence, safe and accountable practice, professional self-confidence, self-regulation and the collective improvement of more considered and appropriate healthcare. Each principle is illustrated with examples from practice and clearly positioned within the professional literature. Written by experts Tony Ghaye and Sue Lillyman
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Reflection: Principles and Practices for HEALTHCARE PROFESSIONALS
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Principled decision making in district nurse practice Richard Griffith
Senior Lecturer in Health Law, College of Health Science, Swansea University
Moral dilemmas in district nursing It can be seen for purposes of the case study that situations arise in nursing practice where no clear conclusion can be
ABSTRACT
This article outlines a case study in which Sister Mary Newsome is in conflict with her district nurse colleague over the care of Margaret, 67, who they visit to monitor blood glucose levels and calculate the insulin dose to manage her diabetes. Recently, Margaret has been refusing to answer the door to the district nurses and has been eating sugary foods that have resulted in five admissions for diabetic ketoacidosis. While Sister Newsome believes continued care at home is best for Margaret, her colleague believes that only residential care will ensure Margaret maintains an appropriate diet and receives her insulin. Sister Newsome considers how best to resolve the conflict over the care of Margaret.
KEY WORDS
w Principled decisions w Morals w Ethics w Dilemmas
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immediately drawn from the district nurse’s understanding of the law or from the professional Code (NMC, 2008). In the case study, Sister Newsome’s view is that a decision to place Margaret in residential care because she is not cooperating with the district nurse team is wrong. Her fellow district nurse believes the patient’s health and welfare is best maintained in a more structured and supervised environment. Sister Newsome is now faced with a dilemma. Both her decision to want to continue treatment at home and the nurse’s desire to have Margaret placed in residential care are lawful. Neither district nurse is proposing to act unlawfully: the decision is one of morality. Morals are influenced not only by the law, but by our culture, religion, beliefs, values and experience. District nurses will find that some clinical decisions are morally acceptable to them, while others are not.
Moral issues and ethical approaches According to Thompson et al (2000), morals and ethics are terms used to refer to social customs regarding the rights and wrongs, in theory and practice, of human behaviour. ‘Moral’ refers to what a person believes is right or wrong based on their culture, experience, upbringing, education and religion. A district nurse may believe that the right to independence and family life should always be respected, and all patients should be treated at home even if they refuse to give their full cooperation. Others may believe that the independence should not be respected where it merely results in the person making unwise choices. It might be argued that it is far better to place that person in residential care to ensure their health and welfare, even if the person is unhappy there. A person’s morals are founded on their beliefs and values. Decisions made by that individual will be influenced by their beliefs and values. District nurses will have their own set of beliefs and values, and their own moral background that will influence decisions when caring for a person. However, what a district nurse considers to be right could in itself be immoral. It could be argued that the patient has a right to refuse treatment and that their autonomy should be respected. As such, a patient must not
© 2014 MA Healthcare Ltd
D
istrict nurses are required to practice in a way that is accepted by law and their professional Code (Nursing and Midwifery Council (NMC), 2008). However, despite positivist claims to the contrary, the law does not always provide the answer to the complex dilemmas faced by district nurses, such as the following. Sister Mary Newsome is in conflict with her district nurse colleague over the care of Margaret, 67, who they visit to monitor blood glucose levels and calculate the insulin dose to manage her diabetes. Recently, Margaret has been refusing to answer the door to the district nurses and has been eating sugary foods that have resulted in five admissions for diabetic ketoacidosis. While Sister Newsome believes continued care at home is best for Margaret, her colleague believes that only residential care will ensure Margaret maintains an appropriate diet and receives her insulin. These situations give rise to questions about whether a nursing intervention is morally acceptable and ethically right. This article will use this case study, based on Re M (Best Interests: Deprivation of Liberty) [2013], to explore the notion of morals as they apply to district nursing and consider what is meant by morals and ethics.
Email: [email protected]
British Journal of Community Nursing October 2014 Vol 19, No 10
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 9, 2015. For personal use only. No other uses without permission. . All rights res
LEGAL be forced to accept treatment just because others believe it is right. Such coercion may be viewed as unprofessional, unlawful and immoral. This gives rise to a moral dilemma that needs to be considered. A moral dilemma, according to Thompson et al (2000), is a choice between two equally unsatisfactory alternatives. Sister Newsome believes that Margaret is capable of making a decision to refuse treatment and that this should be respected (respect for autonomy). Her colleague believes that one must always act in a way that promotes the wellbeing of others and that should include a residential placement, even though it is not the patient’s preferred choice. This is where ethics and the application of ethical principles help district nurses to judge the rightness or wrongness of a decision. According to Edwards (2009), ethics may be described as the enquiry into moral situations and the language employed to describe them. Therefore, ethics involves the application of principles to a moral problem in order to help judge whether an action is right or wrong.
A principle-based approach to ethical decision making A common approach to the ethics of health care was developed by the Beauchamp and Childress (1989) and is based on four moral principles and attention to their application. The ‘four principles’ approach argues that whatever our personal philosophy, politics, religion, moral theory, or life stance, we will be able to commit ourselves to these four prima facie moral principles. The four principles are considered to encompass most of the moral issues that arise in health care. Prima facie means that the principle is binding unless it conflicts with another moral principle—if it does, a choice will have to be made between them. The ‘four principles’ approach does not provide a method for choosing the right answer to a moral dilemma, but it will provide a common set of moral commitments, a common moral language, and a common set of moral issues (Gillon, 1994). The four moral principles are (Beauchamp and Childress, 1989): w Respect for autonomy—respect for the right of an individual to decide for himself or herself w Non-maleficence—obligation not to harm others w Beneficence—requirement to act in ways that promote the wellbeing of others w Justice—obligation to treat others fairly.
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Autonomy The first principle, respect for autonomy, requires respect for the choice made by an individual. In a health-care context, this means that a patient has a right to decide whether or not to undergo any health-care intervention, even if the refusal will lead to harm or death. The term ‘autonomy’ is derived from the Greek meaning ‘self governing’. It refers to the capacity of an individual to make an informed and uncoerced decision about their future. Autonomy is about self-rule with no control, undue influence or interference from others. It involves respect for an individual’s choice
British Journal of Community Nursing October 2014 Vol 19, No 10
based on their own values and beliefs. Gillon (1994) referred to three concepts of autonomy. Autonomy of thought involves deciding for oneself using all available information and weighing this information. Autonomy of will involves the intention to do something as a result of a decision, and autonomy of action involves doing something based on one’s own decision, such as refusing to consent to treatment (Box 1).
Beneficence and non-maleficence Gillon (1994) argues that whenever a health professional tries to help others, they inevitably risk harming them. District nurses must therefore consider the principles of beneficence and non-maleficence together with the aim of ensuring benefit to the patient over harm (see Box 2). The NMC’s Code (2008) underpins a moral and professional obligation to provide overall benefit to patients with minimal harm—that is, beneficence with non-maleficence. To achieve this, district nurses are committed to a wide range of obligations. They must ensure that they are able to deliver competent, safe care, so they need rigorous and effective education and training both before and during their professional careers. They must also ensure that nursing care is of benefit to the patient. In doing this, district nurses must respect the patient’s autonomy. What constitutes benefit for one patient may be harm for another. A mastectomy may constitute an overall benefit for one woman with breast cancer, while for another the destruction of part of her femininity may be so harmful that it cannot be outweighed by the prospect of extended life expectancy.
Justice The fourth principle is justice: that is, an obligation to treat others fairly. Justice includes the principles of fairness, equity and an entitlement to what is deserved. Gillon (1994) suggests the principle can be divided into three categories: w Fair distribution of scarce resources (distributive justice) w Respect for people’s rights (rights-based justice)
Box 1. The right to self-determination Hannah, 13, was found to have leukaemia at the age of 4. After chemotherapy treatment she was diagnosed with a heart-muscle disease called cardiomyopathy: a hole in her heart caused by a high-strength drug she had been given to fight an infection. She then needed a heart transplant but turned it down to return home to die in the company of her parents and siblings because she did not feel she could tolerate more hospital time. Hannah’s wish to go home was, at first, overridden by the medical authorities but she was later allowed to return home. Eight months later she changed her mind and asked to be put back on the transplant list after she suffered partial kidney failure shortly after her 14th birthday. Source: Retter (2013)
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Box 2. Beneficence conflicting with non-maleficence A nurse was so concerned about poor care in the nursing home where she worked that she agreed to participate in a television documentary. The nurse secretly filmed the neglect of elderly patients. She was hailed a hero for her actions by patient groups and fellow nurses and received awards for bringing her concerns to the public’s attention. However, the Nursing and Midwifery Council took a dim view of her actions as the filming was without the consent of her patients and was a breach of confidentiality. She was initially struck off the nursing register for misconduct in April 2009 after admitting breaching patient confidentiality, but said she had agreed to film at the hospital to highlight terrible conditions there. Following a public outcry and threat of court action, the striking-off order was replaced by a one-year caution. Source: Plunkett (2009)
Box 3. Justice for all A hospital spent £20 000 creating a private ward to provide dialysis treatment to a patient, a convicted rapist, who had conducted a reign of terror at a hospital where he received life-saving dialysis treatment three times a week. The hospital had to take out a court order barring him from attacking staff, and it spends £18 000 a year to pay for security guards to escort him during his visits. It pays a further £2000 annually for taxis to take him to and from the hospital to ensure he does not loiter around the building. This is because the hospital felt his human rights would be violated if they refused to treat him. Source: Dickson (2006)
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a patient’s lifestyle will not provide a morally defensible justification for refusing to care for a person with HIV. The principle of justice also requires nurses to obey morally acceptable laws. Even though a nurse may disapprove of the law, they are morally obliged to obey it (Box 3).
Applying the four principles Applying the four principles allows Sister Newsome to come to an ethical decision regarding the future care of Margaret.
Respect for autonomy The principle of respect for autonomy entails taking into account and giving consideration to the patient’s views on treatment. Autonomy is not an all-or-nothing concept. Margaret may not have capacity to decide on accommodation for care and treatment, but this does not mean that her views should not be considered and respected as far as possible. She has expressed her wishes clearly; she does not wish to move away from home. She would be miserable in residential care away from her friends and loved ones. An autonomous decision does not have to be the correct decision, otherwise individual needs and values would not be respected. However, an autonomous decision is one that is informed. Questions to consider are as follows: w Has Margaret been given information about the consequences of the benefits and risks of living at home and cooperating with her insulin management in a manner that she can understand? w Has she been supported to weigh values and belief against the consequences of having or refusing treatment for her diabetes?
Beneficence District nurses must act to benefit their patients. This principle may clash with the principle of autonomy when the patient makes a decision that the nurse does not think will benefit the patient i.e., it is not in their best interests. District nurses must consider both the long-term and short-term effects of overriding Margaret’s views. In the short term, Margaret will be frightened and upset to have to leave her home and move to residential care. This may lead her to distrust health professionals in the future and to be reluctant to seek help. In the long term, there will be a benefit to Margaret in having her autonomy overridden on this occasion. Without treatment, her health will deteriorate. The benefits of acting in Margaret’s best interests would need to be weighed against the disbenefits of failing to respect her autonomy.
Non-maleficence The principle of non-maleficence involves doing no harm to the patient. Margaret would be harmed by moving her to residential care against her wishes. She says she will be miserable there and would rather be dead than in residential care. However, if she continues to suffer diabetic ketoacidosis, her health and wellbeing will suffer.
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w Respect for morally acceptable laws (legal justice). Equality is at the heart of justice. It is important to treat equals equally and to treat unequals unequally in proportion to the inequalities. In the context of the allocation of resources, conflicts exist between moral concerns such as the need: w To provide sufficient health care to meet the needs of all who need it w When this is not possible, to distribute health care resources in proportion to need for health care w To allow nurses to give priority to the needs of their patients w To provide equal access to health care for all w To allow people as much choice as possible in selecting their health care w To maximise the benefit produced by the available resources w To respect the autonomy of those who provide resources by limiting the cost to taxpayers. All these criteria for allocating health-care resources can be morally justified, but not all can be fully met simultaneously. Rights-based justice requires respect for patients’ rights. District nurses have no special privilege as health workers to create rights for patients or decide which rights should apply. For example, a district nurse’s disapproval of
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LEGAL Assessing which course of action would result in the greatest harm relies on assumptions regarding how successful placement in residential care is likely to be and how likely it is that Margaret will be willing and able to cooperate with her treatment at home.
Justice It would be relevant to consider the cost effectiveness of the care and treatment options for Margaret. Decisions cannot be made on purely economic grounds and the district nurse must show that any decision is not discriminatory in accordance with the Equality Act 2010 (UK Government, 2010).
Magnetic importance The principle approach to resolving dilemmas does not give priority to one principle over another, and there may be a need to choose where a conflict occurs (Edwards, 2009). In ITW v Z [2009] the Court gave guidance with regard to balancing the different considerations in relation to applying the four principles in each case.The Court held that the weight to be attached to the principles would differ depending upon the individual circumstances of the particular case. A feature or factor in relation to the principles that in one case may carry great weight may, in another, superficially similar case, carry much less, or even very little, weight. In most cases there are one or more features that are of what the Court calls ‘magnetic importance’ and they will greatly influence or even determine the outcome. In our case study, Margaret’s wish to stay at home and her view that she would be miserable to the point of taking her own life if she were to go to residential care is likely to be of magnetic importance and strongly influence Sister Newsome’s decision making.
Conclusion Despite the increase in health-care legislation as a result of the Human Rights Act 1998 (UK Government, 1998), many situations in district nursing practice give rise to questions that the law cannot resolve, as they call into question whether such practice is morally acceptable and ethically right. ‘Moral’ refers to what we believe is right or wrong, and this is based on our culture, experience, upbringing, education and religion. ‘Ethics’ refers to the application of certain
tation, high quality mentoring s. The book describes a number and the many ways it can be ence, the claims that reflection can nce, safe and accountable practice, and the collective improvement of e. Each principle is illustrated with ed within the professional literature.
PhD, is the founder and Director ning-UK. He is currently involved at aim to improve lives and ipatory and Appreciative Action
, DPSN, PGCE(FAHE) is currently ester and has co-authored numerous
ISBN 1-85642-391-3
9
781856 423915
Reflection: Principles and Practices for
HEALTHCARE PROFESSIONALS
If you are interested in finding out more about the legal cases noted in this feature, please email the editor at [email protected] ITW v Z [2009] EWHC 2525 (Fam) Re M (Best Interests: Deprivation of Liberty) [2013] EWHC 3456 (COP) Beauchamp T, Childress J (1989) Principles of Biomedical Ethics. Oxford University Press, Oxford Dickson N (2006) Attacker given own ward BBC News, 25 April. http://tinyurl. com/nyqmsg6 (accessed 22 September 2014) Edwards S (1999) Nursing Ethics: A Principle-based Approach. Palgrave, London Gillon R (1994) Medical ethics: four principles plus attention to scope. BMJ 309(6948): 184–8 Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. NMC, London. http://tinyurl. com/mz8nb8w (accessed 22 September 2014) Plunkett J (2009) Nurse who secretly filmed for Panorama is struck off register. The Guardian, 16 April. http://tinyurl.com/mrztpkr (accessed 22 September 2014) Retter E (2013) Hannah Jones at 18: I turned down heart transplant aged 13 but I’m so glad I changed my mind. Mirror, July 13. http://tinyurl.com/nwy94h4 (accessed 22 September 2014) Thompson I, Melia K, Boyd K (2000) Nursing Ethics. Churchill Livingstone, London UK Government (1998) Human Rights Act 1998. http://tinyurl.com/prua46k (accessed 22 September 2014) UK Government (2010) Equality Act 2010. http://tinyurl.com/pcane6w (accessed 22 September 2014)
KEY POINTS
w Many situations in district nursing practice cannot be resolved by the law as they give rise to questions about whether such practice is morally acceptable and ethically right w The application of ethical principles to a moral problem will enable district nurses to judge whether an action is right or wrong w When considering a moral dilemma, each principle must be taken into account unless one conflicts with another w Where there is a conflict between principles, there is generally a factor that carries greater weight, or ‘magnetic importance’, on which the decision can be based
New Edition of Bestselling Series on Reflective Practice Reflection: Principles and Practices for Healthcare Professionals 2nd edition New chapters on ‘appreciative reflection’ and the value of reflection for continuing professional development This an essential guide for all healthcare professionals to learn about their strengths, how to develop and use them. Discusses the need for skilful facilitation, high quality mentoring and the necessity for good support networks. Presents key principles and practices of reflection and the many ways it can be facilitated. It attempts to support, with evidence, the claims that reflection can be a catalyst for enhancing clinical competence, safe and accountable practice, professional self-confidence, self-regulation and the collective improvement of more considered and appropriate healthcare. Each principle is illustrated with examples from practice and clearly positioned within the professional literature. Written by experts Tony Ghaye and Sue Lillyman
by Tony Ghaye, Sue Lillyman
ybooks.co.uk
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d the value of reflection for cluded, making this an essential
Reflection: Principles and Practices for HEALTHCARE PROFESSIONALS
ing Reflections: Principles and thors reinforce the need to invest t only for practitioners, but also need to shift attention away from eflection to learn about one’s
principles or theories to a moral problem in order to judge whether an action is right or wrong. The application of ethical principles to a moral problem enables district nurses to judge whether an action is right or wrong by providing a framework that acts as a tool for considering moral problems and resolving dilemmas in an objective, principled manner. BJCN
To order your copies call 01722 716 935 or visit our website www.quaybooks.co.uk
by Tony Ghaye, Sue Lillyman
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