For the purpose of this assignment, ethics in relation to nursing will be discussed. “Ethics; A code of principles governing correct behaviour, which in the nursing profession includes behaviour towards patients and their families, visitorsand colleagues” (Oxford Dictionary of Nursing 2004).
This assignment will consider autonomy as identified in a practice placement, but will also look briefly at the ethical principle of non-malefience that is relevant in this assignment. It will also closely look at this issue and will describe how the principles of ethics apply to practice. In accordance with the Nursing and Midwifery Council (NMC 2004).
Any names of patients referred to in this assignment have been changed to protect their confidentiality. The NMC states as a registered nurse you must guard against breaches of confidentiality by protecting information from improper disclosure at all times. The placement referred to in this assignment is an Elderly Mentally Infirm (EMI) home, which is located on Merseyside.
The United Kingdom Central Midwifery and Health visiting Council (UKCC 2002, clause 6)). Which is now known as The Nursing and Midwifery Council (NMC) Also state that “Health Care Professionals should recognize the respect the uniqueness and dignity of each patient and client, and respond to their need for care irrespective of their ethnic origin, religious beliefs, personal attributes, the nature if their health problems or any other factor”.
Autonomy (“Greek: Auto-Nomos – nomos meaning “law”: one who gives oneself his own law) means freedom from external authority”: Wikipedia, encyclopedia (2004).
On this placement, there were several examples of how autonomy influenced care delivery; this assignment will address two of these examples. The first incident involved an eighty six year old lady called Betty, who suffered with severe dementia, the Practice nurse from her surgery was coming into the home to administer the flu injection to her and several other clients. It had been recorded in Betty’s case notes that she had had a fear of needles in the past and had refused several injections before her mental health had deteriorated, Does an autonomous decision have to be rational? “In the ideal of autonomy day – to -day decisions should be rational, i.e. consistent with the person’s life plans” Hope, Savulescu and Hendrick, (2003 p 34).
Betty had no living relatives to contact to discuss her treatment. Patients suffering with dementia cannot always exercise autonomy. A client may be mentally incapacitated for various reasons. These may be temporary reasons, such as the effect of sedatory medicines, or longer-term reasons such as mental illness. It is important to remember that capacity may fluctuate, sometimes over short periods, and should therefore be regularly reassessed by the clinical team treating the client. The principles of consent continue to apply to any medication for conditions not related to the mental disorder for which they are being treated. The assessment of their capacity to consent to or refuse such medication therefore remains important.
The NMC (2004) recognises that this is a complex issue that has provoked widespread concern. It involves the fundamental principles of patient and client autonomy and consent to treatment, which are set out in common law and statute and underpinned by the Human Rights Act 1998.
The principle of respect for autonomy entails taking into account and giving consideration to the patient’s views on his or her treatment. Autonomy is not an all or nothing concept, an initial step maintaining Betty’s autonomy may be to clarify all the facts in the case, for example does Betty have any understanding of the risks of not having this treatment?
Her mental illness means that she is unlikely to be competent to consent or refuse the injection, but an attempt should be made to explain to her, in terms that she could understand, what the treatment would involve and what the outcome would be without treatment. Has her autonomy been enhanced as much as is possible? If the conclusion is that she is unable to understand the consequences of non-treatment, or that her fear of needles is stopping her evaluating the risks, then she will not be competent to make a decision. However, this does not mean that her fears and concerns should not be acknowledged.
Mill (1982) states “…..the only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him to do so, because it will make him happier, because, in the opinion of others to do so would be wise, or even right” Mill (1982 p 68).
The NMC (2004) Code of Professional Conduct 3.3 states that, “When obtaining valid consent, you must be sure that it is: given by a legally competent person, given voluntarily, and informed”. Crow (1983) suggests that it is the nurse’s responsibility to deliver care within the framework of agreed moral principles, for instance those reflected in the Code itself.
The principle of non-malefience should also be considered in Betty’s treatment, it would seem to be in her best interests to be treated. If the injection is the proposed treatment, the balance of harms and benefits may be such that treatment would causes distress for a short time not such that her life is intolerable. If the decision is to give the injection, then once again respect for Betty’s wishes and concerns should influence the approach to treatment so that her fears are mitigated as much as possible. All medication given covertly must, be recorded in Betty’s case notes for future reference this shows good nursing practice.
According to Wikipedia, Encyclopedia. (2006). Primum non nocere is a Latin phrase that means “First, do no harm.” The phrase is sometimes recorded as primum nil nocereIt is one of the principal precepts all medical and nursing students are being taught in medical school. It reminds a healthcare professional that he or she must consider the possible harm that any intervention might do. It is most often mentioned when debating use of an intervention with an obvious chance of harm but a less certain chance of benefit.
Another example of how autonomy influenced care delivery on this placement was, the entire patient’s case notes where locked away at the nurses station and the trained nurse had the key, if anybody needed the notes the trained nurse had to either get them or issue the key, which had to be returned straight away. This involved the principle of autonomy but also the principle of non-malefience. In any situation where confidentiality is breached, the nurse or doctor must be prepared to justify his or her decision before the General Medical Council.
Respect for patient autonomy (deontological theory)The principle of respect for patient autonomy acknowledges the right of a patient to have control over his or her own life, and this would include the right to decide who should have access to his or her personal information. Where the basis for the duty of confidentiality is the principle of respect for autonomy any breach of confidentiality means that the patient’s autonomy has not been respected, whether or not the patient is aware of the breach. Now due to The Freedom of information act 2000, which came into force in January 2005, patients and carers now have the right to ask to see confidential records.
There are exceptions to the confidentially clause and the principles addressed in this assignment. The National Health Service (NHS) Confidentiality, Code of Practice. This provides generic guidance where there is a need to disclose information that identifies an individual and that information is held under a legal obligation of confidentiality.
“The issues to be considered and the appropriate steps to take can be ascertained by working through the model and referenced text refers to appendix one, two, three. A range of information disclosure scenarios can be found in NHS Code of Conduct Confidentially (2003). These reference and illustrate the model that can be used to aid decision-making. “They highlight issues relating to particular decisions, e.g. disclosure to NHS managers or to the police. It is hoped that they cover many of the circumstances that staff currently have to deal with” (NHS 2003).
In 1997, the Department of Health published the Caldicott Report (‘On the Review of Patient-Identifiable Information’). It considered the flow of identifiable patient information and recommended that confidentiality should be safeguarded by anonymising health data, where possible. “Each NHS organisation must have a ‘guardian’ (normally a senior health professional) to oversee all procedures affecting access to person-identifiable information” DOH Caldicott report (1997).
The NMC code of professional conduct: A standard for conduct performance and ethics (2004) “requires each registrant to act at all times in such a manner as to justify public trust and confidence. Registrants are personally accountable for their practice and, in the exercise of professional accountability, must work in an open and co-operative manner with patients/clients and their families, foster their independence, and recognise and respect their involvement in the planning and delivery of care.”
According to Beauchamp and Childress (2001) there are four principles, which are the most widely used framework and offers a broad consideration of medical ethics issues generally, not just for use in a clinical setting. Ethics are also applied to every day living, and that everybody has their own opinion of what is ‘right or wrong’, to quote Hinchliff, Norman & Schober (2003) “getting in touch with one’s personal value base is a crucial first step in the study of nursing ethics”.
After considering these four Principles, which are general guides that, leave considerable room for judgement in specific cases. “Respect for autonomy: respecting the decision-making capacities of autonomous persons; enabling individuals to make reasoned informed choices. Beneficence: this considers the balancing of benefits of treatment against the risks and costs; the healthcare professional should act in a way that benefits the patient. Non-maleficence: avoiding the causation of harm, the healthcare professional should not harm the patient. All treatment involves some harm, even if minimal, but the harm should not be disproportionate to the benefits of treatment. Justice: distributing benefits, risks and costs fairly; the notion that patients in similar positions should be treated in a similar manner” (Beauchamp and Childress 2001).
This assignment claims that ethics are an important part influence in the delivery of care, but are also a very complex subject, and often leads the Healthcare Professional to examine their own ethical values, it is recommended that a wide range of reading is required to clarify the subject further.
After examining the subject further, it is clear that that in the work place a majority of the delivery of care is, planned with the patients before it is put into practice, which try ‘s to ensure that ethical principles are followed. Professional practice and ethics are changing every day, and it is a complex subject it is also debatable how different people interpret ethics. Ethics is also about questioning our own and others practice “challenging our own and others practice requires courage and vigilance” Kenworthy, Snowy, & Gilling (2006).
Reflection on ones own and other people’s ethical values is a very useful part of continuing learning throughout both career and life, and as a health care professional we must have a good knowledge of nursing ethics and use this in practice rather than personal opinion. In addition, with such issues as euthanasia and cloning, in the news almost every day the ethical pressures on the nursing and medical profession grows stronger. Nurses are seeking to develop further their knowledge of ethics and are increasing their ability to recognise ethical issues in practice.
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