Paternalism can take a number of forms. Unfortunately, because of the governments increasing amount of interaction and funding of the medical industry, governmental paternalism can take the form of limiting funding, which affects treatment options. This form of paternalism is destructive to the health care industry, and is rarely helpful. This form of paternalism also assumes that the government or funding agency knows more about the well-being of my patient than I do, or those involved in their care and treatment. At other times, the individual health care provider, who is immediately involved in the situation may need to take a paternalistic view of his or her patient's well being. In the case of immediate care of the patient does not take away from the patient the rights for self-determination, but aids the patient in the decision making process which is involved in modern health care, paternalistic decisions can be in the patients and nursed best interest.
In the case in which information given to the patient could make no change in the outcome of a procedure, or condition, one could say that deception, or keeping information from the patient would be ethical.
Confidentiality between patient and practitioner is of the utmost importance, and should rarely be breached. However if keeping the information confidential would create greater harm to a wider array of people, the nurse has an obligation to break his or her confidence, such as cases of infectious disease. Also, if the silence would put others at risk of harm, the issues should be brought into the light for evaluation.
Risk is a wide term, and risks to the patient can occur on a number of levels. Risks can arise from the lack of care, from the use of inappropriate care, or from the decisions which the patient makes regarding his or her care. The nurse has an ethical responsibility to allow the patient to make decisions affecting their own well being, and this may put the patient at risk due to his or her own decisions. However, the nurse still has the obligation to allow the patient this choice. This is allowing the patient self-determination.
This is an example of paternalism, and I believe looking into the matter further on the basis of the well being of the child is an acceptable level of paternalist actions, even though it may breach the mother's confidentiality. In this case the health and well being of the child is at risk, and the child is not in a place to protect himself. By remaining uninvolved, the nurse risks harm to another innocent person, therefore addressing the matter with the mother, and then calling to follow up with the other doctor would be an acceptable level if paternalistic involvement. The doctor on the other end of the phone line still has the option of whether or not to divulge information. So the nurse is maintaining accountability for her actions while seeking to work for the benefit of the unprotected child.
Dr. Koop's use of the pregnant woman who has cancer is a great illustration of the dilemmas faced on modern medical practice. Saving the mother in his case study puts the child at risk. His approach to moving ahead with treatment when it may harm the child is representative of both the paternalistic nature of governmental interdiction in the medical industry, and of the federal position which does not assign rights to the child until after birth. The 'doctor knows best' approach is unfortunately based not only on the Dr.'s knowledge, but also the Dr.'s philosophical paradigm, which I do not agree with. The choice is difficult, but expending the life of the child in order to save the mother without the mothers consent would be a breach of medical ethics.
There are three cases in which patient autonomy should be limited. The first, which is the widest category, is in the case of diminished capacity. If the patient's injuries, or if the previous medical treatment has created a state in which the patient is not fully aware of his or her own decisions, then a case for diminished capacity should limit the individuals own decision making. Secondly, if there are external barriers to medical care and treatment which the patient of medical staff cannot overcome, then the medical staff needs to make decisions for the patient. And lastly, the situation may be one in which delaying for the patient, or other persons to make a decision could cause increased levels of harm to come on the patient. In this case also, the medical staff has the responsibility in react in the best interests of the patient rather than delay, and risk greater harm.
In some limited cased, the Dr.'s decision making ability also may be clouded by outside interests, or personal bias. In these cased, the nurse must look out for the patients interest, and possible oppose the Dr.'s orders. The nurse may also have discussed with the patient options, and is aware of patient wishes that have not yet been communicated to the Dr. In this case, the nurse must make a decision to engage the Dr. In a communication process, and risk been perceived as not complying with doctor's instructions.
Often when health care professionals work collaboratively in the field, the solutions to immediate situations which are uncovered by the group are more suited to a situation than what an individual would have thought of on their own.
The health care profession is a difficult, and often stress laden field, and cases may arise which tax the resources of the single individual to their limits. Thus when a health care professional can reach beyond his or her own limits, and task the help of those around her, the collaborative solution is the often the result of a fresh pair of eyes looking at a problem from the outside, out from under the stress and immediacy of the problem.
Racist is an unfortunately active bias which some people hold. And as a nurse, I cannot play the role of the ethics police for every individual. The question is whether of not the person's racial bias affects the care which they offer to the child. It would be my responsibility to watch, and make sure patients were receiving equal attention before escalating the incident, or making any reports to my superiors.
There is a simple procedure to follow which protects the person's individual identity, and at the same time engages the problem. In this case, I would seek to make an opportunity to talk to the person individually. If there indeed was a recurring problem which was affecting the HCP's performance, then I would have to escalate the problem to my immediate supervisor, or to the person's supervisor. The key question is if the person's behavior is jeopardizing patients or care quality. If this is the case, and the person will not listen to my own concerns, then I must bring the situation to the appropriate authority in the chain of command in the organization.
Accurately managing the amount of drugs on the shelf in a facility is a matter of ethics, and personal safety of everyone involved. As the more senior nurse, I would have to spend time discussing the seriousness of the error made by my junior colleague. Two wrongs do not make a right, and it is more important for the correct procedures to be followed, with errors brought into the open than to cover up for mistakes. I would also begin to watch the LPN more closely, to see of there are other areas in which he or she may be covering up for errors and mistakes.
Accepting gifts for services provided can too easily become a situation in which the individual is compromised in their judgment because of gifts which are, or are expected to be received. The care which a nurse offers must be equivalent to all the patients. Whether conscious or unconscious, the practice of receiving gifts from patients can corrupt a nurse's better judgment, and therefore must be disallowed.
Consent - Personal and Proxy
Rawlsian principles of social responsibility, social justice, and collective responsibility would be opposed to the idea of a strike at a health care facility. The health care provider has a responsibility to provide care to those in need of their services. Stepping out of that responsibility in order to personal participate in a strike puts the patient at risk. Therefore, Rawlsian principles of justice, social justice, and collective responsibility would dictate that the strike should be avoided, and other means be sought to correct the labor disputes.
The whistle blower must often ask herself what she is willing to endure as consequences of her actions. The case in which an authority health care provider is making decisions which put patients at risk also inevitably put the nurse at risk as well. The person bringing the problem to the surface must be willing to risk ostracization at best, and…
Sources Used in Document:
Roth, L.H. et al. 1977. "Tests of competency to consent to treatment." American Journal of Psychiatry 134: 279-84.
Wear, S. (1998) Informed Consent: Patient Autonomy and Clinician Beneficence within Health Care. Washington DC: Georgetown University Press.
Nursing values challenged by managed care. (no date) Nursing trends and issues. Accessed 28 April 2004. Available at http://www.nursingworld.org/readroom/nti/9801nti.htm.
Coalition for Accountable Managed Care. (1997). Principles for accountable managed care. Washington, DC: Author.