Applying Ethical Frameworks in Practice
Maria Merritt
Grand Canyon University
Ethical Decision Making
NRS-437V
Teresa Ortner
May 8, 2016

Applying Ethical Frameworks in Practice
Case Scenario:
A 6-year-old develops a high fever accompanied by violent vomiting and convulsions while at school. The child is rushed to a nearby hospital. The attending physician makes a diagnosis of meningitis and requests permission to initiate treatment from the parents. The child’s parents are divorced. The mother, who is not the biological parent of the child, has primary custody. She is a Christian Scientist who insists that no medical treatment be offered for religious reasons. The biological father, who resides in another state, is also contacted. He insists that treatment be given and seeks independent consultation from another physician.
Introduction
Nurses and healthcare workers are faced with ethical dilemmas on a daily basis. In order to determine how to address these dilemmas as they arise a systematic approach should be utilized to achieve a reasonable solution to resolve the issue in question. To make ethical decisions there must be a consideration of the problem and values in conflict, persons involved, the potential consequence of the proposed encounter and the moral reasoning practice chosen to resolve the dilemma. Uustal (1993) offers a systematic approach and nine steps to assist in the decision making process as applied to ethical dilemmas in healthcare. Uustal's model is much like the nursing process and the systematic application of problem solving, but also incorporates an explanation of values when using an ethical decision-making model.
Step 1-Problem identification
In the case scenario presented for evaluation of an ethical dilemma the key individuals involved are the child, his parents who are divorced and living in separate states; this is complicated by the fact the child’s biological father does not have physical custody, the child’s step-mother has primary custody. The situation is a disagreement between the parents of providing consent for emergency treatment of an acute and potentially life threatening illness.
Step 2- State personal ethical position and values as related to the problem
All children are minors and when in the setting of an acute onset of an illness presents in a child medical treatment is necessary to determine the source and provide supportive therapy to decrease pain and suffering as a result of the insult. In this scenario the mother is refusing treatment based on religious beliefs and it is further complicated by the fact she is the step-mother of the child. The question as why the biological father is not the primary custodial parent creates concern and additional questions as to the etiology of this fact. Additional questions as to the underlying unknown factors besides religious beliefs that would have the step mother choose not to consent to treatment. These cause an incongruence with the author’s value system and ethical position for consenting to the medical treatment of minors.
Step 3: Take into consideration factors that relate to the situation and generate alternatives for resolving the dilemma.
As mentioned in Step 2, there are multiple complexities which complicate the situation whereas the step-mother has primary custody and has religious beliefs which object to the pursuit of medical treatment, the biological father lives out of state and requests treatment and there is no mention of how the situation manifested to the separation of the child from his biological parent and remained in the custody of the step-mother. These factors could be addressed and clarified by questioning whether or not there is a court order in place to protect the child from the father as well as delving into the religious consideration for no treatment by determining the religious practice and reviewing its specific ideals and beliefs in relation to this acute illness.
Step 4: Examine and categorize the alternatives. Identify those that are consistent and inconsistent with your personal values.
The most appropriate alternative in this case would be to discuss the Christian-Scientist belief model as it applies to this scenario of a minor child as the option for doing nothing goes against the moral standard of “first do no harm” which is the foundation of nursing in the eyes of the author. Including the rest of the healthcare team involved in the care of this patient would be beneficial in order to ensure personal bias is not clouding the issue at hand, which is not providing any treatment as a result of refusal to consent and an incongruence between the patient’s parents. This removes bias and preserves ethical belief and values stance.
Step 5: Predict all possible outcomes for those acceptable alternatives.
By not investigating and asking questions as detailed in Step 5 and accepting the refusal of consent the patient’s condition could deteriorate to the point of death while causing the patient pain and suffering from fever and dehydration. This alternative is unacceptable as a nurse. Treatment is the only alternative as the right choice based on deontological and utilitarian view. Deontological ethical methods “are categorized by an emphasis upon observance to self-determining moral rules or obligations. To make the appropriate ethical choices, we must realize what our ethical responsibilities are and what standard guidelines are in place to regulate such obligations” (Cline, n.d.). In other words, deontological or duty-based ethics propose that we need do what is right to do and we must cease from doing what is wrong (“Duty-based ethics”, n.d.). The deontological theory guides the duty of the primary physician to act and treat the child. Also ensuring all concerned individuals in this scenario are truly helped, the utilitarian theory should be applied and the patient should be treated. The outcome of an act should produce contentment for the maximum number of persons (Mill, 1863), and in view of the utilitarian philosophy, the minor patient should be afforded with appropriate care.
Step 6: Prioritize acceptable alternatives. List them in order from the most acceptable to the least acceptable.
The most acceptable alternative in this situation would be to obtain consent for treatment of all symptoms and conditions without further delay. Without this consent the next alternative would be to convene and emergent ethics committee meeting in order to determine if state laws enable the provision of care to a minor child when the stepmother’s religious beliefs conflict with the moral implications of denying treatment to the child exist and if the physician may determine this is a situation where medical necessity can override lack of consent in light of the parent’s disagreement on consent for treatment. Step 7: Develop a plan of action utilizing the list of acceptable alternatives.
Once determination of ethics committee recommendations has been received along with consent from patient’s biological father has been considered, treatment should be initiated with rationale for the treatment initiation provided to the step-mother.
Step 8: Implement the plan.
Initiate treatment for patient which includes antibiotics, antipyretics, antiemetics and analgesics for patient symptoms.
Step 9: Evaluate the action taken.
Monitor patient for symptom improvement; communicate treatment plan and outcomes with patient’s father and step-mother; follow-up with ethics committee; reconvene with ethics committee to review hospital policy and state laws which support the decision made to provide treatment to a minor child as in this situation.

Dialogue of interaction with step-mother:
I understand that your religious beliefs are not to provide treatment to the child for any illness, however your child’s condition is critical and life threatening if left untreated. The doctor has spoken with your step-son’s father and he has asked that we provide him with the treatment to stabilize him until he arrives and is able to have the doctor speak with both of you present. The nature of the illness is causing extreme pain and suffering which can be decreased by starting an IV which will give him the fluids he is losing as he continues to throw-up, which is both scary and uncomfortable for a six year old child; we will also give him medication in the IV to slow down the vomiting and give medication to bring down his fever and make him comfortable. Do you have any other questions that I can answer right now as the nurses working with me today are starting his IV and medicating him? I or another staff member will stay with you until his father gets here.

References
Cline, A. (n.d.). Deontology and Ethics: What is Deontology, Deontological Ethics? http://atheism.about.com/od/ethicalsystems/a/Deontological.htm
Duty-based ethics (n.d.). Ethics guide. BBC. http://www.bbc.co.uk/ethics/introduction/duty_1.shtml
Mill, J.S. (1863). UTILITARIANISM. http://www.utilitarianism.com/mill1.htm
Uustal. D. B. (1993). Clinical ethics & values: Issues and insights. East Greenwich, RI: Educational Resources in Healthcare.