In the case of Mrs. Z, her family deserves to know about her situation, because it affects their lives pertinently. Because of the increasing cultural diversity throughout the world, cultural values also play an important part in making ethical decisions in the nursing profession. In the case of Mrs. Z, for example, she appears to have no powers of decision making either in her home or in society in general. Inside the home, her mother-in-law runs the household, while her husband is in charge of important decisions. This could have a significant influence upon her decision not to disclose her condition to her family.

According to Karahanne, Evaristo and Srite (2006, p. 34), for example, also note that cultures seldom influence the individual in singular fashion. In other words, an individual is influenced not only by his or her cultural roots but also by those within which he or she exists on a daily basis. In the case of Mrs. Z, it is possible that her connection with the Western culture made her aware of a desire to make more of her own, autonomous decisions. These observations could also have created a basic uncertainty within her with regard to the legitimacy of her culture.

The interaction of these elements could have driven her decision to not disclose her condition to her family, although this decision was clearly a difficult one for her. Also, the fact that she "appears" sufficiently unhappy to worry her husband creates the impression that she might not be absolutely convinced that her decision was the best one.

According to Wood (2009, p. 20), culture is not the only factor that could have affected the situation with Mrs. Z. Gender and communication are two factors that are closely interlinked with cultural issues. Clearly, the hierarchy in her household precludes any sense of powerful communication regarding matters of importance to the family. This in itself could have strengthened the drive for non-disclosure. Indeed, Wood states that cultural values dictate the way in which men and women communicate, as well as the expectations of results from such communication. In Mrs. Z's household, the generation gap between Mrs. Z and her mother-in-law could also have played a role.

Cultural values therefore play an important part not only in communication, but also in the silences among the family members in the Z. household. According to the case, Mrs. Z is at the bottom of the hierarchy, and is required to either follow her husband's or her mother-in-law suggestions in all areas of her life.

In addition to the conflict that this could create in terms of her observation of the new culture, this could also serve an oppressive function in terms of honesty. Mrs. Z could feel, for example, that she has no power to communicate her condition to her husband or mother-in-law. It could be a perpetuation of the silence that has been her world for the duration of her marriage.

In terms of the health care providers, they stand in a profession with a particular culture, where the main concern is creating an environment of healing and well-being. In addition to respecting patient autonomy, this also means that as little harm as possible should come from decisions where ethical issues are in conflict. The physician and nurse would therefore probably see Mrs. Z primarily as a human being in need of assistance, rather than as a married woman who is under the rule of her husband and mother-in-law.

In making a decision to disclose Mrs. Z's information, they would probably operate from a more typically Western viewpoint as well. One of the possibilities is to first attempt to obtain permission from Mrs. Z to disclose her information to her family members. On the other hand, the non-disclosure could provide Mrs. Z with a temporary sense of power and liberation, even though this will doubtlessly cause her to become increasingly weak and die. Clearly, this makes her unhappy, and she cannot be certain of the wisdom of her decision.

Nursing Interventions

One possibility is to consult with Mr. And Mrs. Z individually to determine the exact nature of the relationship and possible cultural elements between them. In the consultation with Mrs. Z, she could be informed that her information needs to be disclosed in order to retain her life and her relationship with her family. Depending upon her answer, this could be followed by probing questions to determine the underlying reason for her refusing treatment and her failure to disclose her condition to her family. She must be convinced to take treatment by disclosing to her the benefits of such treatment.

Another intervention could be to provide a counselor for the family in order to help them through the difficult time that will follow Mrs. Z agreement to be treated. Such counseling...

And Mrs. Z to act as a mediator between the Western counselor and the couple receiving counseling.
Ethical Decision-making Model

Because nurses are faced with many ethical concerns and dilemmas throughout their years in the profession, decision-making models help to reveal the best choices in difficult ethical situations. There are various considerations that are important in selecting a decision-making model. According to Reeves (2008), all decision making promoted by the process should be supported by valuable elements of the profession, including standards of practice, position statements, research, and evidence-based practice. Policies, procedures, and protocols also play an important role here. It should also be kept in mind that nursing practice in general is a rapidly changing profession. Therefore decision-making models should receive regular updates according to changing policies and procedures.

In the case of Mrs. Z and her husband, the nor-MAN Regional Health Authority's

Framework for Ethical Decision-making (2005) was chosen. The first step is then to collect information and identify the problem. In Mrs. Z's case, the problem is that she didn't share her diagnosis with her family. Ethical components include the decision whether to inform the family from the hospital setting or not. The dilemma is then the conflict between the professional drive to maintain Mrs. Z's autonomy as client while also doing what is best for all involved.

The second step in this model is to clarify and evaluate the issues involved. The greatest ethical concern is that Mrs. Z will die if she does not receive treatment. Her husband is clearly concerned, and deserves to know the truth. The question is why Mrs. Z has chosen to not reveal her situation to her family. This involves not only professional codes of ethics, but also cultural values and expectations.

The third and final step concerns action and review. This means that the professional identifies a range of possible actions and consequences, in addition to the responsibilities of the participants. In the case of Mrs. Z, there are two basic possibilities: Mrs. Z's autonomy can be respected and she is allowed to retain her silence. This means that she ultimately dies, upon which there is a possibility that the hospital could be sued for not doing everything in its power to save her. The second possibility is that Mrs. Z can give her permission to disclose her condition to her family. This would result in her receiving the treatment she needs. It is possible that the family might need counseling in terms of Mrs. Z's position in the household.

Finally, the best possible decision appears to be to attempt convincing Mrs. Z that it is in everybody's interest to disclose her condition and receive the treatment. She may need considerable counseling before giving such permission. However, the best possible consequence will be from her receiving treatment. Hence, the professionals should do what they can to convince her of the merits of disclosure.