The medical healthcare profession is filled with complexity because in this working zone people have to deal with people (healthcare professional with the patients) within the scenario of laws, regulations and practice standards generating huge complexity. This complexity gives birth to legal and ethical issues at the end of time or at the end of life or at the end of the care process. Various different healthcare cases persist their own ethical dilemmas and legal issues where some get resolved with time and some become a matter of confusion and conflict (Gostin, 2010). Elwyn et al. (2012) studied that some of the major reasons giving rise to ethical and legal issues are related to relationships, malpractice, consent and confidentiality. Although there are laws, ethics and standards that work to manage these issues but still conflict occurs due to unintended action, which went wrong, both ethically and legally, yet the intention is considered as correct. This makes healthcare issues and conflicts most complex to be resolved and matter of concern.
Gathering knowledge about ethics and law is considered to be most important part of nursing education. As a nursing professional learner in this study describes one such case scenario of ethical and legal conflict involving assault and battery issue. The learner identifies the stakeholders involves in the case scenario followed by determining the ethical and legal conflicts and explaining them as per rights of stakeholders, healthcare ethics and code of professional conduct. Lastly, the learner with their learning from nursing education tries to propose a legally and ethically defensible resolution to these conflicts in provided case scenario.
Determining the stakeholders
In the provided case scenario, 88 years old lady, Elsie Lee admitted to Residential Aged Care Facility was facing critical health issues and the unwillingness of recovery. She had entered the end of life stage and showed unwillingness of aggressive treatment and resuscitation. The Nurse Manager suggested her to develop her Advance Care Directive (ACD) that will involve her consent about the treatment. However, before getting the ACD developed she cleared that no aggressive treatment and resuscitation is required from her side. Further, in the situation of critical health issues where Elsie was found of developing the emergency condition, the concerned Registered Nurse that is learner suggested her movement to the emergency department of hospital irrespective of her consent. As per learners viewpoint and professional practice missing ACD form side of Elsie was the reason to provide required treatment. Further, the paramedics were also not listening to Elsie’s request to leave her in this situation.
Therefore, Registered Nurse (learner) and Paramedic staff are healthcare professionals that are directly involved in this case scenario. The Registered Nurse due to her action of treatment against the will of the patient and her family put her in this situation and Paramedic staff not listening to the patient’s end of life desire developed ethical dilemma in this case. Further, Bell et al. (2010) indicated that any medical professional should transit the importance information to involved staff related to the patient treatment process. Therefore, Nurse Manager for not providing guidelines to staff even after the expressed desire of Elsie for not getting aggressive treatment and resuscitation puts Nurse Manager also in this ethical dilemma.
As the family of Elsie decided to sue the RN, paramedics and RAC facility, the complete management of Residential Aged Care Facility are including in this case scenario. The ethical and legal issue of assault and battery will involve complete healthcare facility management from Nurse Manager to Administration along with Registered Nurse and Paramedic staff of the hospital.
Differentiating the ethical and legal conflicts
In the provided case scenario, the ethical and legal conflict involves a multidisciplinary complexity where ethical dilemma involves conflict between patient’s respect for autonomy, professional’s act of beneficence and non-maleficence to provide effective care. These three ethical principles clearly structure a conflict in this case scenario. Further, the legal conflict occurs between lack of informed consent and advance care directive from the side of the patient with the duty of care principles from the side of care providers.
The dignity and rights of all stakeholders in this case
The stakeholders directly involve in this case scenario is the learner (Registered Nurse) and paramedic staff where RN is observed to be involved in virtuous and Deontology whereas Paramedic is practising deontology to save the life of patient as per their professional duty of care that affects the patient’s libertarianism (dignity). According to Greenfield & Jensen (2010), the dignity in healthcare is a very important aspect for both the patients and professionals. The concept of dignity involves giving and taking car with complete respect, trust, responsibility and honesty that is applicable to both the care user as well as provider. In this case scenario, the RN practicing as per virtuous and deontology the allegation of battery hurts RN duty of care principles. Gastmans (2013) indicated that as per Australian charter of healthcare rights the professionals and patients have equal right to access, safety, respect, communication, participation, privacy and comment. In the provided case, the stakeholder’s right of participation and respect is been exploited by the family of Elise. The RN had a right to get herself involves in the treatment process which is benne exploited by Elise family.
However, professional (RN and paramedic staff) exploited the patient’s right to comment by ignoring the Elise wish for not getting any resuscitation or aggressive treatment. As Elise was in complete state of conscious her desire or comment should have been considered as a part of treatment process. This led to exploitation of her (Elise) libertarianism and right to comment as per healthcare charter rights. Further, Goethals, Dierckx de Casterle & Gastmans (2012) indicated that as per ethical code of conduct in Australian healthcare, every professional has a duty to provide care to the patient, which is best for the patient as per ethical, legal and healthcare standards. Therefore, while practising as per their beneficence and duty of care, the aspect of ignoring patient consent created complexity in case scenario. The family of Elise not understanding the viewpoint of professionals leads to an issue of disrespect from viewpoint of professional practice in the healthcare. The condition of Elise in this case scenario was very critical and the action taken by RN was the only option to save her life. Therefore, the misperception about the nurse’s duty of care exploits the dignity of stakeholders in this case scenario.
The principles and virtues of health care ethics that inform professional practice
According to Aluwihare-Samaranayake (2012) studies, the healthcare principles design and structure the healthcare practice. These ethical principles involve non-maleficence, autonomy, beneficence and justice. The non-maleficence ensures no harm to the patient rather supports only beneficial treatment. The harm here involves harm of negligence and harm of violation the autonomy of the patient (Butts & Rich, 2012). In the provided case, the RN and paramedic staff practice supported the ethics of non-maleficence by providing only beneficial treatment for avoiding negligence and risk occurring to Elise.
The act conducted by RN also justified by the ethical principle of Beneficence. The Beneficence principle indicates that healthcare processes should only benefit the patient irrespective of the situation. Shorideh, Ashktorab & Yaghmaei (2012) stated that as per beneficence ethical principles the assessment, treatment, actions, act or process in healthcare should aim only to benefit patient irrespective of the situation or circumstances. Therefore, the healthcare conduct committed by Registered Nurse, in this case, is justified as per the ethical principles of non-maleficence and Beneficence.
However, these ethical principles conflict with another ethical principle of patient’s autonomy in this case scenario. Rogers (2012) indicated that as per the ethical principle of autonomy any patient in proper conscious and free of coercion has complete right to take the decision as per their desire of treatment and medical professionals should respect that decision. However, autonomy is applied only when the patient is in a complete state of conscious to take the decision. In the provided case, Elise expressed her desire of not taking any aggressive treatment and resuscitation even before her emergency condition. The only defect was her missing Advance Care Directive (ADC), which she was willing to prepare. However, as this was an end-of-life situation, the RN and paramedic staff has no option other than to provide any treatment to save Elise life. But, this act of beneficence by professionals conflicts with the autonomy of Elise. In end-of-life situation, it is difficult for professionals to accept the unwillingness of treatment without any ADC because it goes against their duty of care (Lillis et al. 2010). Therefore, the ethical principle of beneficence and non-maleficence conflict with the principle of autonomy in provided case scenario.
The relevant codes of ethics and/or codes of professional conduct
Haber & Singh (2012) studied the code of professional conduct that describes the ethically justified nursing practice in Australian Healthcare Zone. There are ten professional codes of conduct that nurses and midwifery need to follow for ethically and legally justified nursing practice. Each and every code of conduct is determined as per ethical principles of beneficence, non-maleficence, autonomy and justice. In the present case scenario, the practice of learner as a Registered Nurse is as per the ethical principles of beneficence and non-maleficence. The relevant code of professional conduct supporting this practice are, code number seven describing that “Nurses support the health, wellbeing and informed decision-making of people requiring or receiving care” and code ten where it is mentioned that “Nurses practice nursing reflectively and ethically” (Moulton & King, 2010). Further, the codes of ethics justifying this nursing practice are “Nurses value quality nursing for all people” and “Nurses value access to quality nursing and healthcare for all people”.
These were the relevant code of ethics and professional conduct that work to justify the nursing conduct or act of learner as a Registered Nurse in this provided case scenario. The sole aim of nursing practice is to provide best possible care for their patient, however, certain situations, phenomenon’s and viewpoint restrict this practice but still providing the duty of care is the legally and ethically justified action of any healthcare professional.
Proposing legally and ethically defensible resolution
The major identified issues in this case scenario are lacking professional informed consent or Advance Care Directive from side of patient followed by ethical dilemma between the autonomy of the patient and act of beneficence conducted by Registered Nurse and Paramedic Staff that is considered to be assault and battery by the family members of Elsie (patient) after her death. Ulrich et al. (2010) indicated that informed consent is a legal process where the patient or their family members need to sign an official form declaring their consent regarding treatment process. Therefore, as there was the unavailability of informed consent and advance care directive in this case, therefore, the act of Registered Nurse in this scenario can be ethically justified in this case.
According to Aw et al. (2012) the overall between beneficence and autonomy can be resolved by establishing Ethics Committees that work to resolve the conflict of complex matter. For the given case scenario, the establishment of an ethical committee would be a good resolution technique where the chairperson from institution along with other members like the counsellor, professional. Psychologist and philosopher will work to decide the best judgement for provided case situation. This ethical committee is a legally and ethically functional as per Australian Health Ethics Committee (1996) recommendations.
This ethical committee is an internal complaint resolution team of Aged care facility (RAC) that will follow Aged Care Act 1997, Complaint Principles 2011 and Aged Care principles provided by Australian Government (Gostin, 2010). This committee would work to explain the viewpoint of healthcare professionals to the family members of Elise and would expect honesty from the side of healthcare professionals. Ulrich et al. (2010) indicated that internal complaint resolution is the first act and instance to attain timely and sustainable solutions for improving aged care services. Therefore, this ethical committee should be considered as first and foremost resolution process implemented by Aged care facility to resolve the case issue.
The provided case scenario of patient Elise was detected to be an ethical dilemma between the beneficence and non-maleficence of the professionals and autonomy of the patient. The absence of advance care directive and informed consent also created complexity for professionals regarding the treatment process required at the end-of-life stage of Elise. As ethical dilemma is the part and parcel of healthcare professional where one has to deal with human lives, therefore, it is recommended to organisations for being prepared with resolutions to solve such issues regarding the ethical and legal conflict. For the provided case scenario, learner provides a resolution technique of establishing an ethical committee to handle the internal complaint by processing a meeting to explain and analyse the situation aspects for getting a proper judgement. In the provided case scenario, learner placed as Registered Nurse involves in ethical dilemma needs to be honesty for her action of treatment and situation for getting the proper judgement.
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