QUESTION TWO: ADULT CASE STUDY, AN ETHICAL ISSUE OF CONSENT.
This essay presents a critical incident analysis of a 70 years old man refusing to give consent to a life saving treatment. The essay will discuss its impact by discussing the conflict between professional and the patient’s issues. It will go on to explain the main professional issues in the scenario, breach of any NMC code of conduct and show how they relate to the guidelines set by Nursing and Midwifery Council (NMC). It will also highlight on the relevant underlying legal or ethical principles that applies to the case study and its implications. For instance, ethical principles, such as beneficence, non-maleficence, autonomy, justice, human rights and the best interests of the patient will be explored, in the light of relevant laws, in order to show some of the legal and ethical complexities within this case study, and finally draw a conclusion. For confidentiality purposes, have been changed in accordance to the NMC guidelines.
The main professional issue reflected in this case study is the issue of consent. Consent, means to give permission for something to take place or to agree to do something (oxford dictionary 1998). This does not necessitate that, the actions approved have been developed or permission given in the knowledge of possible consequences known as informed consent has been achieved. This goes to show that, for medical purposes, although the patient has the right to refuse treatment, he has to also have the requisite mental capacity (Dimond 2008). This case study brings out a clash between Mr. A’s autonomy and the nurses professional duty of care. Clearly, it is essential for the nurses in charge of Mr. A to take all reasonable precautions to ensure that he has appropriate counselling and all the necessary information in making the decision to undertake his treatment (Dimond 2008). The NMC (2008) expects nurses to ensure they gain consent in every procedures that requires consent. Although the nurse gave consent and tried to convince Mr. A in this case study, he refused due to his religious belief. The nurses will have to adhere to his decision because the NMC (2008) code of professional conduct upholds nurses to treat patients as individuals, respect their cultural values, religion, age and beliefs as well as recognise their diversity. Mr. A is assumed to be a Jehovah witness man and since he is competent and autonomous, it is his competent right to refuse blood transfusion without being forced or tortured to undertake treatment as stated in the article three of the human rights act (Baker 1998). More so, as pointed out by Dimond (2008), it is important to ensure that, when a patient refuse treatment, he or she has the mental capacity to make a legitimate decision without been subjected to unjustified influences of another person according to the section one of the (Mental Capacity Act 2005).
Again the scenario raises questions about respect for individuality and the duty of care for the patient. The issue of respect for individuality is debatable in this case study as a result of the comment made by the other nurse who was standing by. The nurse saying “she did not see why they were making a fuss about Mr. A’s refusal as he was old and probably didn’t have long to live anyway”, was not fair. It can be argued that, that was a prejudiced comment she made. The nurse failed to respect Mr. A as an individual not recognising him as a partner in her care, respecting his preferences and not acknowledging and valuing his rights (Brinnie and Titchen, 1999 p.16). This can also be seen as age discrimination because the nurse made that comment purely on the basis that, the man was old and therefore, treatment or not he would die anyway. Occasionally with this type of issue, open communication is enhanced by sharing and team work. Walter (2001 p.219) stated that, “the most effective teams appear to consist of people who undertake different but complimentary functions”. This nurse although she had her doubts failed to work in partnership with the other nurses who were convincing Mr. A to undertake his treatment. This comment could have posed a challenge to Mr. A around whom the proposed treatment was being planned if he had no grounds of refusing treatment. It is important for Patients to be treated with respect by nurses who demonstrate that they are sensitive to individual’s needs, values, and beliefs and regardless of their age or medical condition (NMC 2008).
It is based on the above professional issues that ethical principles and legal laws need to be applied in this scenario. Fletcher et al, (1995) defines ethics as “a branch of philosophy concerned with the character and conduct of individuals”. For a nurse to act ethically, means they are acting rightly and with good conduct. In most dilemmas of ethics ethical principles which are principles that provide essential framework for working out moral dilemmas and problems Beauchamp and Childress (2009), needs to be applied.
The first principle, the principle of autonomy, expresses the idea that, professionals have a responsibility to treat patient according to the patient’s wishes, inside the boundaries of acknowledged treatment and to guard the patient’s confidentiality (Bird and White 1995). Under this principle the nurses main duties are to involve Mr. A in his treatment decisions in a significant manner, by taking into account Mr. A‘s wishes, needs, capabilities and protecting his privacy. Although Mr. A may not be completely autonomous and lawfully not competent to refuse treatment, ethically, his views concerning his treatment must be considered and respected so long as he is autonomous (Burnard and Chapman 2004). In the health care settings, this means that, the health care provider is obligated to respect the patient’s right to make decisions for himself (Dimond 2008). Based on his religious beliefs, he has communicated his wishes thus, the nurses may only interfere in his decision when they believe Mr. A does not have adequate information, mental capacity to understand or is being coerced. As stated by Burnard and Chapman (2004) in other for a person’s needs and values to be respected, an autonomous decision does not have to be the correct decision. However, an autonomous decision must be informed. For instance, Mr. A was given enough information about the consequences of refusing blood transfusion in a way that he could clearly understand. He has been given the necessary support to weigh his values and beliefs against the consequences of his refusal to treatment. Since he has the right to self determination, independence and freedom, the nurses have no duty to assist him in carrying out damaging decision, nor do they have duty to assist him to harm himself. The principle of informed consent is embedded in autonomy (Benjamin and Curtis 1992) and for this reason, the NMC (2008) expects the nurses to provide Mr. A with relevant information which will aid him to make an informed decision.
The concept of beneficence is another principle evident in the case study. Duncan (2001), explains beneficence as the concept of doing good. This means that, nurses or healthcare professionals have the responsibility to work for the benefit of their patients (Rumbold 1999). The nurses in this case study have the opportunity to intervene on Mr. A’s behalf regardless of his wishes. The NMC code expects nurses to act in a way that benefits patients (NMC 2008). However in his scenario, this is not possible because Mr. A’s decision not to take the blood transfusion, will not benefit him and it is not in his best interest. This is a life saving treatment or a treatment without which Mr. A’s health will be irreparably damaged or might lead to death. As stated by Hendrick (2001), this kind of situations like Mr. A’s usually poses one of the most acute dilemmas for nurses. However, the human right act, article 3, he is not to be tortured or forced to take the blood transfusion (Reid 1998, Baker 1998). If he is forced, by law, this will be claimed as a breach of patient’s autonomy (Baker 1998). This brings out the clash between the principle of beneficence and autonomy. If the nurses override Mr. A’s views regarding his treatment and act in what is in his best interest, with his autonomy overridden, it will be of benefit to him in the long term. Under this principle, the most relevant aspect of the nurse’s obligation is the competent and timely delivery of treatment that is within the boundaries and the circumstances presented by Mr. A with due consideration being given to his religious belief. This is so because, under the law, providing patients are competent, they have the legal right to refuse treatment (Hendrick 2001, Dimond 2008). The nurses are not justified in overriding the refusal to consent to the blood transfusion, the benefit of acting in his best interest would need to be weighed against the disadvantages of failing to respect his autonomy. This ethical consideration applies whether Mr. A’s decision is irrational or not. Although it might be thought to be irrational, the law, states clearly that, irrationality does not mean incompetence (Hendrick 2001), but an unreasonable decision should be respected where it is based on long-held beliefs and values (Kennedy 1991).
The non-maleficence principle can also be applied because it is the obligation that, nurses or health-care workers do no harm to their patients (Tschudin 2002). This principle expresses the concept that professionals have a duty to protect the patient from harm. Harm is defined as the “thwarting, defeating or setting back the interests of one party by causes that includes self harming conditions as well as intentional and unintentional actions of another party” (Beauchamp and Childress 2009). According to the case study, if the nurses had forced Mr. A to undergo treatment it could cause emotional strain on him and drastically affect him, impact his relationship with the nurses and other professionals and how he views himself. The nurses would have gone against the ethical principle of non-maleficence if carried on with the treatment. It is evident that, the nurses want to do all they can to prolong Mr. A’s life but because they do not want to cause harm, they are faced with a conflict of principles. Their wish to act in the Mr. A’s best interest, the principle of beneficence is difficult to reconcile with the nurses moral duty to respect Mr. A’s autonomy. Yet in the absence of any reason for acting paternalistically, the nurses need to do him no harm and respect his wishes. Due to this, they have little choice but to go along with Mr. A’s decision. As the NMC guidelines (2008) states, “nurses must treat patient with respect and ensure they seek consent. Also Dimond (1999) stated that, nurses must respect patient’s refusal just as much they would their consent. Since the assumption is that, Mr. A is competent, it can be said that, his refusal is not based on false beliefs. Consequently going against his wishes will cause him great harm.
Additionally, it is important to consider the impact that the decision about the treatment will have on Mr. A. Nurses are obliged to be fair to all patients. Fairness in the sense that, they give all required information, alternative to treatment if there is any in hope that, the patient will make an informed decision (Dimond 1999). In this scenario, it is fair that they treat Mr. A according to his specific needs. For instance, Mr. A has the right to be treated equally to any patient regardless of age, gender or religious belief (NMC 2008). The notion of justice is to be fair to all patients and the only time limits can be placed is, when it interferes with human rights (Reid 1998). It is not fair to force patients to take treatment however, the nurse standing by’s comment was unfair to Mr. A because she came across as discriminating against Mr. A because he was a 70 years old man. However because he is a competent adult, who is refusing treatment regardless of the effect on his life, the nurses are morally and legally obliged to value his decision and act upon the law (McHale and Tingle 2007).
Finally, to act in the best interest of Mr. A in this case study would be to make the decision about his blood transfusion especially if he was unable to make an informed decision for his care. Conversely, this would be what the nurses and his relatives decide is best for him. However, in this case study, it is very relevant to consider Mr. A’s expressed wishes either formally or informally. Legally the nurses are expected to have regard for patients especially when they are acting on behalf of vulnerable people who lack the capacity or are incompetent (Dimond 2008). With reference to (Edward 1996) the nurses can only act in the best interest of Mr. A lacked the capacity to refuse treatment. On the other hand, since he is autonomous and competent, from the legal perspective, his decision not to be transfused cannot be overridden by the nurse’s best interests.
In conclusion, this essay has discussed the complexity of gaining consent and the significance of the NMC code of professional conduct. A critical analysis of this case study has revealed the ethical principles involved and its impact on the patient and professional values. These principles of ethics have provided a means for deciding the right answer to a moral issue and explored the different ethical considerations relevant to consent. The essay has discussed the awareness of patient and professional issues in nursing. In legal perspective, actions by nurses are usually taken in the best interest of the patients however because Mr. A was autonomous and competent, by law his wishes could not have been overridden by the nurses best interest. Therefore what seem as the expertise of the nurses cannot be hailed over the choice of this patient in this scenario.

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