In the process of providing care to patients, health care professionals face ethical dilemmas such as the decision to inform or not to inform the patient about a fatal illness. It is very crucial that these issues are addressed appropriately without causing any harm – physical or emotional – to the patient. Although it may not be possible for healthcare professionals to respond to some of the ethical issues, they must ensure that they ease the discomfort of the patient and their family as much as possible while staying true to the ethics professionalism. In this regard, this paper reviews the four ethical principles: autonomy, beneficence, non-maleficence and justice, as proposed by Beauchamp and Childress (2001) and explores its application and usefulness in guiding health care professionals, especially nurses, to address the ethical issues they face.
Health care professionals frequently encounter ethical issues while providing care to their patients. Facing these issues and handling them appropriately can be the biggest challenge for them. Although it is not always possible to give a definite reply to some ethical dilemmas, as health care workers, the motive must be to reduce the level of discomfort of patients. In this regard, Beauchamp and Childress (2001) suggest a four dimensional response, also known as the four clusters, to help healthcare professionals to address these issues. These four clusters are: (1) respect for autonomy (2) non-maleficence (3) beneficence and (4) justice. In first principle the respect for autonomy is a norm of acknowledging and respecting the decision-making capacities of autonomous people. In second principle, non-maleficence, is a norm of avoiding the causation of harm. In third principle, Beneficence is a group of norms for providing benefits and balancing them against risks and costs. Finally, in the fourth principle the justice includes norms for a fair distribution of benefits, risks, and costs. These four principles, alone or in combination, are considered as bases for all the decisions that are made with regards to medical ethics (Gillon, 2003). Lawrence (2007) also considers the foundational principle of biomedical ethics. The aim of the present paper is to review and reflect on these principles of ethics to see their application in specific real life scenarios from the perspective of nursing staff specifically in situations where the nurse has to decide whether to disclose a certain piece of information to their patients or not.
Gillon (1994) describes autonomy as “self-rule” or in other words a person's ability to make his own decisions.Stoljar(2007), believes autonomy to be the basic right of a person on which all the other rights depend. According to Gillon (1994), it is the moral responsibility of healthcare professionals to consult the patients before taking an action for them or on them. Hence, the principle of autonomy means that the patient has the right to make their own decision. In order to enable the patient to make an informed decision and for the decision to be successful, it is mandatory to acquire and provide all the information available so that all the positive and negative aspects can be weighed before making a decision (Stoljar, 2007). By not giving all the information to the patient about their illness their autonomy is not acknowledged. This situation also poses a question on the professionalism of the medical staff particularly doctors and nurses who need to be truthful to the patient but at the same time have the responsibility to take all the necessary steps to avoid further harm to them. At the same time, they should keep in mind that the truth of terminal illness and prognosis may negatively impact the patient and they may give up all the hopes in life. It can also cause psychological trauma to the patient which can further worsen their condition. In scenarios, the role of the family of patient in decision making cannot be overlooked. Patients cannot always make their decisions alone; their family should be allowed to participate in the decision making process. The family alone chooses the decision on behalf of the patient often. Whatever the situation, a health care professional has to be honest to their profession and the patient at the same time.
It is also essential for a nurse to understand the patient and their family and it comes with experience and wisdom. If a nurse has good theoretical knowledge and practical wisdom she can make a wise judgment and attempt to respect patient's autonomy. However, the wisdom of an individual may not be enough for taking a decision of great magnitude as it can have a significant impact on the patient's life. As a result, Gillon (1994) recommends intense training and education of healthcare professionals so that they can avoid the violation of ethical principles.
If a patient is terminally ill, it does not always mean that the patient is incapable of making his own decisions or does not have the required level of mental capacity to participate in decision making. Thus, thinking that patient will always take such news as negative may not be the right conclusion. The patient, on the contrary, may attempt to put more efforts towards the cure of his illness. There have been examples when patients with terminal illness have managed to live longer than estimated. In this case, the patient, after knowing about his condition, may also choose to opt for alternative medicines. Thus, by limiting access to information, the patient is being restricted to participate in their own therapy which is a serious/clear violation of autonomy.
Beneficence can be described as acting in the best interest of others. Cullity (2007) defines the term as “furthering the welfare of others”. According to Cullity (2007), since the ultimate goal of healthcare professionals is to benefit the patient, all the issues are connected to the principle of beneficence. Though, its description is easier to comprehend, its application is altogether difficult and challenging. Drawing to the best interest of others (in this case, the patient) requires a deep understanding of the patient's characteristics and their family background which, in most cases, is not available to the nurse. In the absence of the above, a nurse may not have any other option but to honor the family as well as the doctor's decision to hide the particular information if it appears to be in the best interest of the patient. However, if the nurse has a sufficiently detailed data about the patient and their family, believes that telling the truth is beneficial for the patient, then the nurse must consult other colleagues as well as doctors and apprise them of her justification of beneficence. Moreover, her competency, assertiveness and courage to take initiative for the benefit of the patient are essential. In other words, a nurse should construct a collective wisdom and based on that, draw a conclusion.
On the other hand, if the nurse does not possess these skills, she may remain silent and just follow the decisions made by others. Non-active participation in decision making can be caused by the influence of medical professionals or higher authority on a nurse or a perceived threat of losing her job. These two factors may withhold a nurse to work in patient's beneficence. However, the notion of compassion also comes here and an individual needs to decide which course of action to take.
Avoiding any act which could harm the patient in any way is never a choice of nursing professionals. However, this creates a need to strike the right balance among all the ethical principles, as one principal (autonomy) may demand to give all available information to patient but this autonomy can be at the cost of other principles (beneficence and non-maleficence). The distinction between beneficence and non-maleficence is also necessary to understand as the two principles appear to be overlapping since working in the best interest of the other could essentially mean providing no harm to the patient. However, this is not always the case. A simple example of this could be a diabetic patient whose leg amputation has to be done to save his life. In this scenario, harm has been given to the patient (violation of non-maleficence) but the act has been done in the best interest of the patient (beneficence). For situations like these, Lawrence (2007) and Gillon (1994) suggest that healthcare professionals should weigh the benefit against the harm in order to make an appropriate decision.
A nurse should not assume that the family's or doctor's intention of keeping the patient uninformed about their terminal illness is intended to protect the patient. The nurse should deeply analyze the situation at hand to come to a conclusion with regard to protecting the patient from any harm. The nurse, as described earlier, is also in a dilemma as the guiding ethical principles appear to be interlacing with each other requiring the nurse to be truthful. However, others are also doing no harm to the patient. The question of what constitutes harm the patient is equally important because the nurse will first have to ensure that informing the patient of their terminal illness will not lead to any psychological or physiological harm to the patient. A simple example of this could be that patient in the case scenario may also be undergoing a severe but treatable illness. Informing such patient about his disease could harm the patient instantly and create significant problems to the patient's health.
Applying and ensuring fairness and equality at all times and without regard to gender or race is one of the main principles of Nursing Ethics and professionalism. According to Beauchamp (2007) treating a person justly is treating them with fairness. For applying the principle of justice, nurses must have the attitudes of objectivity and impartiality. A nurse must voice a concern when they feel that justice is not being provided to the patient; however, concerns should be raised on a suitable forum so that any misunderstanding or wrong deduction by a nurse could be clarified. Justice, as per the case scenario, may simply demand a nurse to be fair and apprise all patients with terminal illness about their conditions without giving regard to the peculiar condition under which each patient is. However, such approach would be detrimental to beneficence and non-maleficence principles.
It can be seen that all the principles seem to be overlapping and therefore reaching to concrete conclusion is challenging. Understanding each principle separately and deciding on the basis of them is subjective and may vary from case to case. The nurse's aptitude which will come into test every time to encounter such cases. Sticking to collective wisdom and voicing the concern on the right forum are very important as these strategies help in avoiding chaos and make decision making more effective and strategic. Being truthful to the patient can also be a wise choice but decision must be made by considering all the ethical principles, human rights and one's own accountability and honesty with the profession.