How to Overcome Ethical Challenges as a Nurse

Conflict-of-Interest Case Analysis

There are a number of ethical challenges faced by Kathy's provider in this case. Issues of disclosure, truth telling, protection of patient rights, preserving the nurse's integrity (by not ordering diagnostic work that is not needed -- both the patient's mother and the hospital are putting pressure on her to order this), transparency, accountability, and conflict-of-interest are just a few of the ethical challenges faced by the provider in this case. Each should be met as it arises and dealt with in the order that it appears over the course of the presentation.

The first challenge appears when the mother requests a chest X-ray, which is unnecessary at this stage (but because she has requested it and the practice manager wants diagnostic test stats up, it could be arranged to please both the mother and the practice manager). However, to protect the integrity of the nurse, it should be refused: if a nurse compromises her own integrity by ordering diagnostic work that is unnecessary it places a strain not only on her own conscience but also on the system as a whole. Unnecessary diagnostic work does nothing but move money from the patient's (or insurer's) pocket to the pockets of the hospital -- without any real or needed service being provided. The nurse who has integrity will be transparent and honest with the mother at this moment and say that such a test can be ordered but that at this moment it is not necessary, as there are a number of alternatives that can be utilized in order to assess the health of Kathy. However, a second ethical challenge appears at this point -- and that is the recommendation of Kathy to see the MD, who is known for overprescribing and ordering unnecessary diagnostics tests. This would obviously please the mother, but it could be negative for the patient, who is the one who would actually be prescribed something she may not need.

If I were the provider, I would not even entertain the idea of recommending this MD, as his reputation speaks volumes. Indeed the clinic itself appears to have a conflict-of-interest at heart, as the practice manager has stated that he wants to see more diagnostic work being ordered. (Instead of ensuring that the right tests are being conducted, the manager is more focused on meeting quotas, thus indicating that the clinic is being run with a "profits first, people second" philosophy). With regard to this practice manager, I would continue to only order diagnostic work that I thought was in the best interest of the patient. I would go to work with a "patient first" mindset rather than a "profit first" outlook and recommend a change in the workplace environment (Page, 2004).

Another challenge appears when the mother urges the provider to sign a form saying that Kathy is not contagious so that she can go on the trip with her dance troop to Ontario. This is an ethical challenge related to honesty and transparency, truth telling and disclosure. For the provider to sign such a document would be to place not only Kathy at risk but also the members of the dance troop at risk as well. Were I the provider in this case, I would explain to Kathy's mother that doing so would not be a good idea because it could potentially lead to a matter in which litigation becomes a possibility and no one wants that to happen.

A fourth ethical challenge arises when the provider spots the tattoo wound that appears to be infected, indicating that Kathy is in need of antibiotics. Yet Kathy does not want her mother to know of the tattoo. This is an ethical challenge related to the Minor Dilemma and the protection of patient's rights (what to disclose to the parent, what to keep private between the minor and the provider). In this case, while it is important to preserve the trust between the minor and the provider, the mother is still the legal guardian and has a right to know what treatment is being prescribed for Kathy. If I were the provider I would speak privately to the mother so as to avoid embarrassing Kathy and in order to ease the situation along. I would explain that Kathy has a small tattoo that appears to have developed into an infected wound that can be cured with an antibiotic.

However, as this situation has already been discussed with a colleague, yet another challenge arises: the colleague suggests that the provider simply sneak the antibiotics to Kathy so that her mother does not know. This is an idea that encroaches on the integrity of the nurse and the ethical responsibilities of disclosure, truth telling, transparency, accountability. The provider has a duty to be accountable to both Kathy and Kathy's legal guardian; thus, there should be no behind-the-back provision of antibiotics. For the sake of transparency, the infection should be made known to Kathy's mother. Full disclosure also warrants this. And basic truth telling would be supported by making this discovery known. Were I the provider, on this point I would be firm: I would not take the advice of the colleague but would instead discuss the matter with Kathy's mother -- yet I would do so in a respectful manner so as to keep emotions in check (Mayer, Salovey, 2001).