Introduction
Ethical conflicts have been a subject of concern and in discussions in many science
disciplines. Due to the advancement in medical practice and technologies, the healthcare
providers often face challenges to make appropriate decisions especially in situations where
complex situations may arise in practice (Fisher, 2011). This essay discusses ethical conflicts
where the healthcare providers are torn between respecting patient’s rights and doing no harm
ethical principle. The discussion helps one to understand healthcare ethics and law and their
relevance in decision-making processes that ultimately uphold patient’s rights and protects them
from danger (Beauchamp & Childress, 2013).
This paper explores Case Study 1 to identify the ethical conflict present in the case study.
The essay will also explore the ethical and legal aspects of the identified ethical conflict in
relation to ethical theories, principles of health care, professional code of ethics, professional
standards of conduct as well as the national and international charters. The context analysis will
be done so as to provide an appropriate solution to the identified ethical conflict.
Case study 1:
This case study is about an adult patient who has ended –stage cancer. Mr. Harry Nelson
has exhausted all the treatment options and is currently receiving palliative care at his home,
where he lives with his daughter. He has no advanced care directives. When his health
AN ETHICAL DILEMMA 2
deteriorates, he refuses to go to the clinic which forces his daughter and the paramedic’s team to
transport Mr. Harry to the clinic forcefully (Paramedics Australia, 2011).
Through this case study, the impact of ethical principles autonomy, beneficence,
nonmaleficence, and justice during decision-making processes is evaluated. In addition, the
concepts of utilitarian and consequentialism ethical theory will be used to explore the impacts of
Paramedics Australia professional code of conduct, Australian Nursing and Midwifery Council
professional standards, national and international charters (Statute law and Common law,
Australian Charter of Health Care, Universal Declaration of Human Rights (UDHR) in ethical
decision making processes.
Ethical conflict
The ethical conflict central to this case study is autonomy vs. beneficence and
nonmaleficence (save a life vs. respecting patient’s rights). In this case, the healthcare
professionals intentionally used the paternalistic approach during the decision-making the
process as they believed that this was the most beneficial approach to Harry and his family.
Although the intervention seemed to be useful for the patient, it breached the ethical principle of
autonomy by disrespecting the patient’s wish. Such situations require that the health care to
critically analyze the benefits and risks associated with their decisions, along with the
consequences associated with the decision making process. The decision made should be the one
that promotes maximum beneficence and with the most minimal harm (Jones & Creedy, 2012).
Legally and ethically defensible approach that address the ethical conflict
Nursing profession in Australia is influenced by the four bioethical principles developed
by Beauchamp and Childress including; a) autonomy- need to respect patients rights, b)
AN ETHICAL DILEMMA 3
beneficence – do good to prevent harm, c) non-maleficence – avoid causing harms and d)
justice- fair distribution of resources to ensure equal and fair treatment to all clients (Banks &
Gallagher, 2009). In this case, the principle of autonomy applies in terms of patient’s rights and
obligations. Based on this principle, Harry has the right to make decisions about their medical
treatment. According to Beauchamp and Childress, autonomy refers to as being “free from
controlling influences or personal limitations such as inadequate understanding” (Beuchamp &
Childress, 2013, p.56). Therefore, the healthcare provider is obliged to remain truthful (veracity)
to their clients and to respect their choices. Relating to the case scenario, the healthcare team that
transports Harry to the hospital against his will violates this ethical principle by not respecting
the patient last wishes and therefore Harry has no choice to decide for himself which inhibits his
autonomy (Kerridge, Lowe & Stewart, 2013).
Further analysis of the scenario, Harry’s daughter, and the medical team decision to
forcefully transport his father to the hospital raises the questions about the family’s intention.
Evidently, her intentions are good and this brings up the ethical principle of beneficence and no-
maleficence. The ethical principle of beneficence mandates the healthcare professionals to treat
their patients in a manner that is of maximum benefit to the patient (Australian Medical
Association, 2004). On the other hand, the ethical principle of nonmaleficence assures that the
actions of the healthcare providers do not cause harm. This basically implies that the main
responsibility of the healthcare providers is to avoid doing any harm to their patients. This
ethical principle correlates with the ethical theory of utilitarianism which argues that the
healthcare professional’s actions should provide “highest good for a maximum number of
people” (Berglund, 2012).
AN ETHICAL DILEMMA 4
Utilitarianism theory supports the idea of taking actions that offer maximum benefits at
minimized risks and costs (Tonti-Filipini, 2011). In this situation, the health care provider’s
decision to transport Harry to the hospital for more treatment favors the intention of the family
members but it does not favor Harry’s decision but it may positively impact the psychological
well-being of the patient. This act outweighs the ethical principle of autonomy in regards to the
nurse obligations to non-maleficence. However, this act may negatively affect the patient-
physician relationship and may lose the trustworthy relationship with the patient. In addition,
forcing the patient into treatment may make him depressed and could lead to serious mental
complications such as suicidal attempts. In this case, the principle of beneficence may prove to
be of benefits but the probability of causing harm is high (Doran et al., 2015).
The ethical principle of justice focuses mainly on equality and fairness in the distribution
of the healthcare resources. There are different forms of justice including rights based justice and
distributive justice. In rights-based practice, the principle states that every person has the right to
access care plan (Catholic Health Australia, 2001). In this situation, the healthcare team violates
Harry rights because he was forced to participate in care plan without his consensus. This is an
ethical conflict because the patient had no limitations that he would not be able to make an
informed decision. Based on the consequentialism theory, the healthcare provider’s action was
appropriated as the consequences of taking Harry to the hospital was the choice that was likely to
yield more net benefit as compared to loss (Tonti-Filipini, 2011). Therefore, this theory justifies
the acts of overriding patient’s decision to refuse further treatment as Harry’s decision could have
resulted into serious harm (Townsend & Luck, 2013).
Every nurse primary commitment is to the patient, and their main role is to advocate for
the patient’s rights, with the aim of protecting patient’s health and safety. A nurse is expected to
AN ETHICAL DILEMMA 5
maintain professional’s integrity during care delivery. This is supported by Universal
Declaration of Human Rights (UDHR) which mandates that healthcare providers should deliver
care based on the patient’s needs and with unrestricted considerations of class, personal
attributes, economic status, or the nature of the disease (AHPRA, 2012). Based on these nurse
values, the healthcare provider decision to forcefully transport Harry to the hospital for further
treatment was appropriate. However, on this value, the nurse owes the same duties to the patient
including maintaining cultural competence and to preserve integrity when determining the
appropriate action and consistent with their obligations to provide optimum care. This value was
violated by the nurse actions as they are expected to practice with compassion and to respect
patient’s dignity (Freegard, 2012).
Australian Charter of Healthcare states that healthcare providers are also expected to
conduct themselves in accordance with the relevant laws relevant to the nursing practice. The
professional standards nursing and Midwifery Board of Australia outlines the professional codes
of conducts. Nurses are expected to deliver safe and with competence. In addition, the nurses are
also expected to respect culture, dignity, values and beliefs of the person receiving care
(Australian Nursing and Midwifery Council, 2008). They are expected to promote and to
preserve the trust as well as the privilege the inherent in the relationship between the people
receiving care and the nurses. In addition, healthcare providers are required to deliver care to any
person who is need of the care and anyone who refuses to deliver it commits a crime and is liable
to imprisonment. They are mandated to work in good faith and without any recklessness. This
rule is established by the Medical Practitioners Act 1938 (NSW) and the current Health
Practitioner Regulation National Law Act which states that it is illegal for any health care
provider who fails to deliver satisfactory care without any reasonable cause, unless the healthcare
AN ETHICAL DILEMMA 6
provider proves that they have taken all reasonable steps to save the patient and within a
reasonable time (Australian Health Practitioner Regulation Agency (AHPRA, 2012).
All treatment procedures normally require consent, but there are key legal factors that
determine of a person can receive treatment without consent including; a) the patient’s mental
health capacity, b) if there is advance care directives, c) the degree of urgency based on the
patient’s health and situation and d) if there a substitute decision –maker (usually a relative) is
present and is able or willing to make the decision (Forrester & Griffiths, 2015). Where the
patient is unable to give consent or substitute decision is absent, this legal requirement is usually
waived under the Statute law and Common law. In this situation, the principle of patient
autonomy is outweighed by the Common Law (Atkins, de Lacey & Britton, 2014). This is
because, Under the Common Law, a health care provider is expected to deliver urgent treatment
to the patient, if the healthcare provider acts honestly and reasonably believes that the treatment
provided is needed to prevent serious complications to the patient’s health. In addition, the
healthcare provider’s decision is supported by the principle of necessity in Common Law. This
principle justifies a healthcare provider actions of giving treatment even in the situation where
the patient’s condition is not life threatening and also without the patient’s consent (Australian
Commission on Safety and Quality in Health Care, 2012).
Analyzing context and proposing a solution
In my opinion, there is no perfect answer for the identified ethical conflict. It is not easy
to reach a perfect situation, but the situation can be analyzed using ethical decision-making
process and by applying the best possible principle. However, it is evident that two ethical
principles conflict; beneficence or non-maleficence vs. autonomy (Fisher, 2011). Nurse’s action
AN ETHICAL DILEMMA 7
to respect patient’s autonomy implies that she or he is accepting the patient’s decision and in
other words, increasing serious harm to occur. However, the healthcare in-charge carried out
actions against Harry’s expressed wishes which would be expected to result in the ‘net benefit’
of improving his health condition and quality of life (Forrester & Griffiths, 2015).
Reinforcing this action is nurse professional standards that emphasize that the primary
nurse duty is to help and save lives (Fisher, 2011). Although the professional conduct of ethics
asserts that the appropriate course of action should be chosen on behalf of the patient (with or
lacking capacity) should be in line with the patient’s beliefs and values so as to promote their
autonomy and to act in their best interests, but in this situation, the resulting consequences would
have been harmful to the patient (Ozolins, & Grainger, 2015). Therefore, it would have been
morally right to override Harry’s decision. However, one fundamental aspect of a nurse role is
advocating for patient’s rights, making sure that they are adequately informed, supporting and
respecting their decision (accept or decline treatment) and to involve them when making
decisions about their care. In cases where there are disputes, then it would be advisable to obtain
legal guidance from the courts. In a case where a decline of care would lead to serious harm to
the patient, the professional guidance is crystal clear that the patient’s wish must be respected
(Morrison, & Furlong, 2014).
Conclusions
The complexities of healthcare practice are increasing as the health care sector continues
to evolve. This case study provides useful insights into the nature of ethical dilemmas faced by
the healthcare providers in their daily practice. Therefore, it is important to understand the ethical
and legal frameworks governing decline of treatment and capacity. This case study has helped
AN ETHICAL DILEMMA 8
me understand the role of nurses when making ethical decisions and the importance of upholding
patient’s rights while preventing doing harm.
AN ETHICAL DILEMMA 9
References
Atkins, K., de Lacey, S. & Britton, B. (2014). Ethics and Law for Australian Nurses (2nd ed.).
Port Melbourne: CUP.
Australian Commission on Safety and Quality in Health Care (2012). Safety and quality
improvement guide standard 6: Clinical handover ACSQHC, Sydney. Retrieved from
<www.health.gov.au>
Australian Health Practitioner Regulation Agency (AHPRA). (2012).
