In order to create such a resolution and usually to resolve an ethical dilemma nurses use four fundamental ethical principles of nursing care and practice, which are considered by many experts as a cornerstone of ethical guidelines.
The first one is autonomy. This principle means “that individuals have a right to self-determination, that is, to make decisions about their lives without interference from others” (Silva, M. Ludwick, R., 1999b, p. 4). It is also possible to define empirically that autonomy consists of two elements: data acquired or proposed as a presupposition and reaching the decision as the action.
The second is beneficence. This principle is thought to be a basis of day-to-day nursing care and practice. “The principle of beneficence and utilitarianism direct health care professionals to make an ethical decision to provide the maximum benefit and to minimize harm to the greatest number of people involved” (Silva, M. Ludwick, R., 1999b, p. 4).
Beauchamp and Childress (1994, p. 192) state that “Each of … three forms of beneficence requires taking action by helping – preventing harm, removing harm and promoting good….
” (cited by Silva, M. and Ludwick, R., 1999b, p. 4). This ethical principle may cause some ethical questions when a dilemma regarding performing of a mentally ill patient’s wishes appears.
The third fundamental ethical principle is nonmaleficence or “do no harm”, which is easily connected with the obligation of a nurse to defend safe keeping of the mentally ill patient. “Born out of the Hippocratic Oath, this principle dictates that we do not cause injury to our mentally ill patients” (Silva, M. Ludwick, R., 1999b, p. 6).
The fourth basic ethical principle is justice. This principle implies “giving each person or group what he/she or they are due” (Silva, M. Ludwick, R., 1999b, p. 7). This principle applies to parity, integrity or another point that may be fundamental for the justice decision. In nursing care and practice the principle of justice usually centered on rightful admission to nursing care and on rightful allocation of scarce resource.
Rightful admission to the care means that nurses are easy of access to provide nursing care and a mentally ill patient as well as any member of a society realizes that nursing care is completely accessible. “The principle of justice … guides health care professionals to treat every client with fairness and equity regardless the prognosis of illness, social and economic status of clients, the social and financial consequences impose on others” (Wilcockson, M., 1999, p. 21).
Though it is necessary to remember what actually has the priority if we will compare it with nurse’s good, a nurse sometimes mixes up with what the nurse considers to be a mentally ill patient’s good. It is questionable what composes “good” for a mentally ill patient without violating his or her autonomy or allowing the mentally ill patient to suffer bitterly. And can it be ethical to abolish the choice of the mentally ill patients.
For example Beauchamp and Childress (1994, pp. 277-278) maintain that paternalism can obtain two forms a weak and a strong one. They assert that weak form paternalism implies is that a nurse defends the mentally ill patient’s good when he or she is incapable to resolve some questions as a consequence of problems like depression or the effect of medicaments. But a strong form of paternalism, they say “…involves interactions intended to benefit a person despite the fact that the person’s risky choices and actions are informed, voluntary, and autonomous” (cited by Silva, M. and Ludwick, R., 1999b, p.5).
In the proposed case study the old lady didn’t write DNR order, thus, the nurse behaved just adequately. She remembered about her duty to a mentally ill patient to preserve her autonomy but it was no possibility for her and for her mentally ill patient to “identifying and addressing problems in the decision-making process” as the lady was too depressed. Her quality of life was decreasing ad she couldn’t live independently but it was still questionable were these reasons adequate enough to make end-of-life decision.
On this ground it is necessary to investigate the notion of “quality of life”. This obscure notion implied the situations when decisions concerning the question of withdrawing nursing care are formed and “…based on the likely low levels of self-awareness, reasoning, communication and activity that the mentally ill patient will have and the low probability of improvement” (Thompson, E., Melia, K. M. and Boyd, K. M., 2001, p. 44). Usually it is not up to mentally ill patient to make quality-of-life decisions as they are often reached by doctors or relatives.
In other words “quality of life” should be determined by mentally ill patients themselves being able to evaluate it adequately. The unproved understanding of notion is often used in statements like: “After all, we shouldn’t waste any more money on this person because their quality of life will be so low, anyway” (Hunt, G., 1994, p. 125)
Considering the case study we may that the “quality of life” of the old lady was not so low as to bring to end-of-life solution. However it was up to the mentally ill patient to decide that problem independently as it was her right to create DNR order but she didn’t do it, besides her depressed state and, thus, low self-determination was among the main reasons for reasonable nurse’s acts.
If we try to use these four fundamental ethical principles to the case study that was chosen for our investigation beforehand we will be able to evaluate the deeds of nurse from ethical point of view. For example, it is clearly evident that nurse violated the principle of autonomy because autonomy of a mentally ill patient means the opportunity to make decisions about his or her life without interference of others. If taking into account this principle then it was up to a seventy three year old woman to decide either she needs to obtain emergency CPR or not. This principle was thus violated by the nurse, and the reasons for such behavior are not deciding in this matter.
She might have ignored this principle basing on the other principles that prevent a nurse from doing harm, meaning to rescue the life of her mentally ill patient because human life is valuable and unique. But while the nurse deprived her mentally ill patient of the possibility to choose life or death, the nurse thus made herself responsible for this decision, which is evidently wrong. At least, the nurse should have noted that the mentally ill patient didn’t want to be rescued.
As for beneficence, we may suppose, on the other hand, that it was a demonstration of weak form of paternalism. In such case the nurse protected the good of a seventy three year old lady as she was incapable to resolve end-of-life questions as a result of her depression and decreasing of the quality of her life. Consequently the deeds of the nurse were well-taken and righteous.
But the nature of the action is also ambivalent, as the nurse might have been directed by her own notion of good, or the notion that the nurse obtained while studying ethics. The nurse shouldn’t have been define independently if the woman was really unable to make reasonable decisions, the nurse must have at least objectively estimate the problems and conditions of the mentally ill patient that led to such mentally ill patient’s intention.
This thought may also be confirmed and at the same time called in question by the principle of nonmaleficence. The nurse protected the safety of her mentally ill patient, but without mentally ill patient’s wish. It is questionable, would be the note of DNR be regarded as the injury caused to the mentally ill patient. If the life and conditions of this old woman were so poor, they made her suffer; the nurse must have taken it into account while deciding what would be more or less painful for her mentally ill patient. This may be regarded as the intention to take off responsibility from the nurse.
Observing the last principle of ethics, justice, it is necessary to note that this principle was violated by the nurse. Her mentally ill patient was at least due to be heard. Her wishes and demands should have been taken into consideration, moreover, the mentally ill patient did not ask to help her die, and she just wanted to prevent her from suffering in future.
Thus taking into consideration these four main principles, the case seems to be contradictory. It seems that the nurse acted basing upon her own notion of what is good, safe and just for her mentally ill patient, without taking into account the demands, wishes, living conditions and problems of her mentally ill patient. Of course, definite peculiarities of these principles allow justifying the actions of the nurse, if we look at the situation form the point of view of value of human life.
One more issue that should be examined is the absence of mentally ill patient’s order for DNR. This may also be a reason to justify the actions of the nurse. But as soon as the demands was heard by the nurse, the nurse should have defined this problems with the mentally ill patient and helped the woman write a necessary order, if it was her wish.
Nurses often can’t decide what their actual point of view about some ethical dilemmas is and how far those perceptions go. Anyway nurses should have to do with their own system of moral values but at the same time to determine whether it “fits into the big picture” (Stacey, J., 1998, p.8).
It is necessary for a nurse to take a turn for the better foreshortening of problems and challenges in the area of care by forming at any rate a “bifocal view” of the problems (Stacey, J., 1998, p.7)
Of course, not all ethical dilemmas concern death. “Nurses deal with ethics on every eight-hour shift. …for example, the Nursing Code of Ethics says to hold all things confidential, but sometimes there is information others need to know,” explains Freeman (cited by Stacey, J., 1998, p.4).
However nurses often can appear in the situation of resolving of a complex moral dilemma that regards an appeal for assisted death. This problem is one of the most complicated issues in nursing practice. This question is also a key one in the case study that we have in some way already investigated earlier. Given the poor quality of life that seventy-three years old woman would probable suffer she demanded not to perform any heroic measures in the event of cardiac arrest. So she does not want to live anymore. But when the nurse sees the mentally ill patient next she is being resuscitated as there was no Do Not Resuscitate order (DNR) in her notes.
Hunt, G. (1994) Ethical issues in nursing. Routledge.
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Silva, M. and Ludwick, R. (2002). Ethical Grounding for Entry into Practice: Respect, Collaboration, and Accountability. Online Journal of Issues in Nursing, 30 August, 2002. Available from [Accessed 14 February 2006]
Silva, M. Ludwick, R., (2003) Ethical Challenges in the Care of Elderly Person. Online Journal of Issues in Nursing, 19 December, 2003. Available from [Accessed 15 February 2006]
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Thompson, E., Melia, K. M. and Boyd, K. M. (2001) Nursing Ethics. 4th ed. [n.p.]
Wilcockson, M. (1999) Issues of life and death. [n.p.]