Addressing Ethical Dilemmas in Nursing

Daily nursing practice implies many challenges, including the need to make decisions from an ethical point of view. One of the most problematic issues is whether the medical staff should consider the decision of the patient who refuses to take further treatment even if this may lead to the patient’s death or the treatment should not be stopped despite the patient’s choice. This ethical dilemma may be considered using the following scenario: a 41-year-old woman with developmental delays from birth asks to stop the treatment of advanced breast cancer. It is thus rational to review how the ethical dilemma in the provided scenario can be identified, addressed and solved considering the application of Consequentialist ethical theory.

Primarily, it is necessary to look into the definition of ‘ethical dilemma’ in accordance with the Code of Ethics because the International and National Code of Ethics for Nurses is considered as the dominant guideline in ethical decision-making in the nursing practice and research (Mallari & Tariman, 2015, p. 54). Next, the evaluation of potential solutions under the Consequentialist perspective should be provided. And, finally, the solution to the dilemma and its consequences must take place. When addressing the ethical dilemma in the case of the refusal of the terminally ill patient from treatment, it is normally regarded as ethical to follow their will since it deprives the latter from the painful and anguished demise.

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The crucial ethical dilemma in the scenario is whether it is right to follow to mentally delayed patient’s desire to refuse from the treatment in case this act may lead to death. On the one hand, the patient is an adult person who is aware of her diagnosis and who recognizes the absence of recovery opportunities. As advanced breast cancer is considered incurable, the further treatment of cancer for the patient would mostly include pharmacological treatment to reduce the pain, improve the quality of life, and allow them to live longer. It, naturally, means that further treatment will not lead to recovery, but will postpone the death and help to manage pain. As it is clear from the scenario, the patient has developmental delay since birth, which makes it more difficult to identify whether she is conscious of her decision and its consequences. Hence, the issue is not “to treat or not to treat”, but whether it is legal and morally right to follow the opinion of the patient, who might not fully recognize her choice. Nevertheless, the type of the patient’s developmental delay is not specified, therefore, her awareness of the action cannot be denied. According to the Code of Ethics, one of the nurses’ values and ethical responsibilities is to “promoting and respecting informed decision-making” and “honoring dignity” of the patient (Canadian Nurses Association, 2017, p. 3). However, it is also stated that nurses should promote “health and well-being” (Canadian Nurses Association, 2017, p. 3). Moreover, it is required that the nurses should ensure that any of the patient’s choices should be legally supported with the person’s informed consent (Canadian Nurses Association, 2017, p. 3). Thus, there are two ethical dilemmas in the scenario: whether the patient can stop treatment if it leads to death and whether the resolution of the patient can be the foundation for the official refusal from treatment.

After the core values in ethical decision-making related to the scenario are provided, it is worth reviewing the consequences of such outcome that will inevitably follow. In any case, the continuation of treatment despite patient’s will or the cessation of treatment in accordance with patient’s will must both be compulsory based on her family agreement and its official confirmation, namely consent. It is worth keeping in mind the value of human dignity, which should become the focus in ethical decision-making since patient’s dignity is professional value of the nurse, so the nurses should consider socio-cultural circumstances of the treatment and patient’s own acceptance of death (Parandeh, Khaghanizade, Mohammadi, , & Mokhtari-Nouri, 2017, p. 1; Fernandez-Sola et al., 2017, p. 3). The first option – continuation of treatment despite the patient’s desire to refuse from it contradicts to the following principles of nurses’ ethical care: promotion and respect of informed decision-making, respect to dignity and not causing lesser harm. As a result of this decision, the patient’s condition will worsen because the treatment will flow in the opposition with her decision. Next, the treatment that will not lead to recovery will endure patient’s suffering due to the incurable disease they have. The patient as well as her family will suffer longer; besides, the expenses will increase due to the need to maintain patient’s condition during the unidentified period of time. Stopping treatment in accordance with the resolution of the patient appears to be ethical because the patient will fill able to control their own life. Apart from it, the patient will temper pain for shorter time, which will decrease the overall suffering. This option is also beneficial from the financial point of view since it allows reducing the expenditures on treatment and maintenance of the patient’s hopeless condition. The only contra-argument may come from the legal perspective: since the patient has developmental delays, it should be legally articulated whether the patient is capable of conscious decision-making or not. In case this fact has not been confirmed, it might be questioned if the patient was fully aware of her act and if the nurse has not ensured it. In case the patient’s awareness has been confirmed, the patient should be asked whether the nurse should inform her family about her choice and her health condition. If the patient has agreed to disclose this information, her relatives should be informed about it; otherwise, the aforementioned data should be kept a secret. In case it has been concluded that the patient is not capable of making conscious decisions, the individual(s) who can do it instead of them should be identified. These people should be responsible for deciding whether the medical staff should follow patient’s will or continue treatment.

After the possible variants and their consequences are described, it is worth underlying that the last option is the only viably decision from the point of view of ethics. It then seems to be ethical because: (1) it allows examining and considering patient’s ability of conscious decision-making; (2) it allows following patient’s chosen course of treatment as much as possible; (3) it removes the responsibility for decision-making from the nurse to the patient or his family; (4) it prevents the nurse from participating in legal issues and does not presuppose questioning their competence. Though this may look ethical, it does not prevent from three conflicting situations: when the patient cannot legally make decision and her family does it for them but opposite to their desire, when the patient’s will should be followed, but the family should not be informed about such choice, or the family does not agree with it and requires reviewing this resolution. Although solving ethical dilemmas in the right way remains difficult and never removes complicated consequences, the most important determinant of the ethical decision should be patient’s dignity (Kadivar, Mardani-Hamooleh, & Kouhnavard, 2018, p. 2). In the given decision, the most probable outcome of the patient is dying with dignity, which should be accompanied by culture-competent care where the patient’s understanding of death is considered (Hemati et al., 2016, p. 3).

It may be concluded that the identification and evaluation of ethical dilemma implies several steps: identification of nursing standards based on which ethical problem may be identified; identification of ethical dilemma; the selection of ethical theory to examine the ethical dilemma; the analysis of potential solutions and their consequences; deeper evaluation of ethical decision. At each stage, it is extremely important to make sure that human dignity is considered since it is the greatest value. Also, it is worth ensuring that the treatment follows the patient’s choice if he is legally capable of making his own decisions and that the suffering of the patient will be minimized in case the disease is incurable. In case nurses follow the International and National Code of Ethics for Nurses, their practice will become more ethical, which will improve the way they care about the patients.