Talia Bardash and Jay Kolasinac
Professor Kirk, Biomedical Ethics Paper
A patient presents to the hospital with a fractured arm and then informs the nurse confidentially that her fractured arm was not due to a fall, which was her original statement, but rather because she is the victim of intimate partner violence. The patient asks the nurse not to document or inform the attending physician of the true cause of her injury. By doing so, she will not be examined or treated for any other injuries that may have been caused by the incident.
The ethical question here is should the nurse disclose the true cause of the patient’s injury or should she honor the patient’s request for nondisclosure?
Autonomy and beneficence are the two major ethical principles that are most relevant to addressing this ethical question. Autonomy means “the right to make independent decisions concerning one’s own life and well-being.”[1] Beneficence is “promoting someone else’s good or welfare.”[2] It is advocating for the orientation towards the good of the patient. Along with beneficence, nonmaleficence is a principle that ensures that all preventable harm is prevented.
We believe the nurse should disclose the true cause of the injury to a supervising physician based on the ethical principles of autonomy and beneficence.
We decided that the nurse should tell the supervising physician that the patient is a victim of partner violence because of the ethical principles of autonomy, beneficence and non-maleficence. Firstly, autonomy is the right to participate in decisions about your care. The first aspect of autonomy is free action. Free action is the action of liberty and the ability to choose between what you do and do not want for yourself as opposed to someone else choosing for you. Autonomy is diminished when someone or something presents itself as an obstacle in your way. In this case, the patient states that she does not want the nurseto tell her supervising physician and wants the information to stay between them. However, it is clear that her free action is diminished by the fact that she is being abused. She clearly wants to get medical care and obviously wants to be treated properly, hence why she had informed the nurse. However, the nurse has to be wary and evaluate if there are any obstacles in this situation that are preventing her from making the decision that she would want to make. The case makes it sound that the patient does have decision making capacity. She seems to be alert and oriented and aware of the decision that she wants to make. However, the fear of the violence of her partner could act as an obstacle in preventing her from seeking true and accurate care. So we would not be able to say that the patient exhibits the true definition of free action.
Second principle within autonomy is effective deliberation. Effective deliberation is ensuring the person is able to gather all of the relevant information regarding their case and then taking that information and making a decision that is rational. In regards to this principle we don’t feel that she was provided with the relevant information about the consequences with each option. It does not seem that the nurse sat down with her and discussed the issues and the benefits and harms of each side. For example, does the patient understand that this may lead to her not being provided accurate care and then does the patient recognize the issues and consequences of not being treated properly. Furthermore, was the patient given the benefits that she would receive if she did provide the supervising physician with the truth?
The third principle is authenticity. Authenticity is confirming if the patient’s decision is consistent with their values and character. We would have to conclude that here, the patient is not consistent in her choices. The fact that she informed one provider but not the other is inconsistent. Therefore we cannot declare that she is being authentic in her decisions. The last principle is moral reflection, which is making sure the patient is involved in introspection and being able to constantly evaluate their values and see if the decisions agree or disagree with those values. We do not believe that we have enough information to decide if the patient is capable of moral reflection. However, we have seen that the patient does not have the first three necessary principles for autonomy. Therefore, because of this we would say that the patient does not possess the true autonomy and the nurse should then proceed to tell the supervising physician the information.
The second major principle guiding our decision is beneficence. Beneficence is promoting the good/well being of the patient. Benefits are defined by trying to work towards the patient’s goal, while harms are defined by anything that moves away from the patient’s goal of care. Here the patient admits that her goal is to not have the supervising physician know that she is a victim of partner violence. However, through this goal she is subjecting herself to not get the proper care and treatment for her broken arm. By telling the supervising physician we also may be able to provide the patient with the proper resources and guidance for her. At the moment, her decision prioritizes her privacy, however, it limits the benefits of the health care treatment that she will be able to receive. Through this we arrive at non-maleficence, which means inflicting the least amount of preventable harm to reach a desired outcome. By keeping the information from the supervising physician we are inflicting preventable harm on the patient. She will not receive the proper care and will not be examined or treated for other injuries that she may have from this incident that we may not be aware of. It is because of both autonomy and beneficence that we believe the supervising physician should be told.
We do acknowledge that there is a strong counter-argument for not telling the supervising physician. The patient has confided in the nurse and created a very intimate and personal relationship with the nurse. She is trusting in the nurse to provide her with a certain level of security. By telling the supervising physician, the patient may begin to no longer trust the nurse and even the healthcare system.
Even though we may distance the relationship between the nurse and the patient, we believe that the patient will benefit more from having the supervising physician aware of the situation because of the ethical principles of autonomy, beneficence and nonmaleficence, as stated above, the supervising physician should be told. While the patient may have decision making capacity she does not have the proper elements for autonomy. Secondly, through weighing out the benefits and harms we found that the patient was subjected to greater harm by not telling the physician of this violence.
As such, we believe that through the ethical principles of
autonomy and beneficence the nurse has a responsibility to tell the supervising
physician of the partner violence.
[1] Yeo, M et al. (2010). Autonomy [selections]. In M Yeo et al. (eds.). Concepts and Cases in Nursing Ethics. [3rd edition] Ontario: Broadview Press, pp. 91-97, 103-109.
[2] Yeo, Michael et al. (2010). Beneficence . In M Yeo et al. (eds.). Concepts and Cases in Nursing Ethics. [3rd edition] Ontario: Broadview Press, pp. 103-116.
