bioethics nursing

1. This case is complex and multilayered, as the speakers say. It touches upon several major bioethical issues include respect for patient choice, otherwise known as the principle of patient autonomy. The case also addresses the important issues surrounding physician bias, as well as the lack of competencies in physician communication and physician awareness of diversity issues. Although the diversity issues in this case pertain to same-sex couples, it could just as easily have been a case involving culture or any other diversity variable. Although the speakers did not mention medical paternalism, that is something that comes up in this case. Even had the couple been straight, it is possible the doctor would have disregarded the advanced directive, which would have indicated medical paternalism.
The speakers also did not mention the doctor’s point of view, or that of the hospital, both of which are important to take into consideration when analyzing the ethics of the case. Doctors operate under the broad parameters of the Hippocratic Oath, with its stipulations to do whatever it takes to save lives. This directive does come into direct contact with the more modern principle of patient autonomy, which is why medical paternalism can prove problematic. Even when a doctor thinks he or she “knows best,” they still have an ethical obligation to defer to patients’ wishes. That obligation is covered under the rubric of deontological ethics, like the speakers indicate. Bioethics have shifted to elevate the status of patient choice over the desire of a doctor to preserve life at all costs. Sullivan (2003) calls this normative shift “the new subjective medicine,” in which the patient—not the nurse, doctor, or anyone else—decides whether they want to be intubated, whether they want to be on life extension, or whether they prefer to let nature take its course. Of course, this mode of ethical thinking overlaps with discourse related to patient autonomy when it comes to euthanasia and physician-assisted suicide, too. A refreshing resolution to the ethical dilemma posed by cases like these is offered by Quill & Brody (1996): the “enhanced autonomy” model, which “encourages patients and physicians to actively exchange ideas, explicitly negotiate differences, and share power and influence to serve the patient's best interests,” (p. 763). The matter of physician bias is a separate one, and does need to be addressed more thoroughly in hospital policy as well as iin medical school education.

References

Quill, T.E. & Brody, H. (1996). Physician Recommendations and Patient Autonomy: Finding a Balance between Physician Power and Patient Choice. Annals of Internal Medicine 125(9): 763-769.
Sullivan, M. (2003). The new subjective medicine: taking the patient's point of view on health care and health. Social Science and Medicine 56(7): 1595-1604.


2. This case involves striking a balance between respecting the patient’s right to alleviate pain—even if it means self-medicating—and the healthcare worker’s obligation to protect the dignity of the patient by preventing addiction. The speakers frame the issue mainly as one related to patient dignity and duty to practice, but issues related to patient autonomy are also at stake here. If a patient-centric perspective is taken in which the patient determines the ideal outcomes of treatments, then it would follow that continuation on the opioids may actually be the best choice of action. After all, if the patient were to switch to a method of pain relief that did not work, the patient would be suffering. In order to alleviate one type of suffering (the pain), the patient opts for another (addiction). This can be viewed as a matter of patient choice, however repugnant a healthcare worker finds addiction complicity. In fact, healthcare workers also have many misconceptions about opioids, addiction, and their duty to care (Pappagallo & Heinberg, 1997). When addiction is put into the global perspective of the patient’s overall health status and prognosis, decisions can be made more effectively.
As the speakers point out, healthcare policy does recommend a case-by-case, and evidence-based approach to dealing with situations like these. Pappagallo & Heinberg (1997) discuss the ways healthcare workers can assess patients for prior addiction and prescribe accordingly. Likewise, the speakers mention the Prove Opiod Risk (POR) evaluator, which has a relatively high degree of accuracy. If such assessments were made prior to prescribing the drugs, addiction could have been prevented. Entwistle, Carter, Cribb, et al (2010) recommend dutiful communication between healthcare workers and the patients, to ascertain the best strategy for pain management, to assess the patient’s willingness to tolerate pain in exchange for long-term mental health gains, and to understand whether non-addictive alternatives might be efficacious.

References

Entwistle, V.A., Carter, S.M., Cribb, A. et al (2010). Supporting patient autonmy. Journal of General Internal Medicine 25(7): 741-745.
Pappagallo, M. & Heinberg, L.J. (1997). Ethical issues in the management of chronic nonmalignant pain. Seminars in Neurology 17(3): 203-211.