Nurses have to make ethical decisions between what is ‘ wrong’ and what is ‘ right’ on a daily basis. The nursing profession is based on ethical code of conduct. Ethical conduct is an important aspect in the delivery of quality care. Nursing ethics allows nurses to provide care that is patient centric and observes patient autonomy and privacy. There are different theories used to make ethical decisions in nursing. Each theory has its limitations and often, ethical decisions are made after careful analysis of a case. Culture plays a critical role in ethics as what is right and what is wrong is largely determined by cultural, religious and legal values. In this paper, an analysis of nursing ethics and cultural values is conducted in view of the case study of Mrs. Z, an expatriate wife who has a tumor, has withdrawn from treatment, and would not like her family to know about it. Relevant ethical theories applied in nursing practice are identified and related to patient confidentiality and reasonable limits to confidentiality. The influence of cultural values on ethics and ethical conflict resolution is analyzed in view of this case study.
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An ethical theory is a model that can be applied to make ethical decisions and resolve ethical conflict. Various theories such as deonatology, utilitarisim, virtue ethics and moral particularisim are applied in nursing practice. Deonatology is a normative ethical model based on duties and obligations and does not invoke the consequences of an action when determining its moral worth. Nurses have duties and obligations to their patients and all actions they take should be guided by these moral duty and obligations (Vanlaere & Gastmans, 2007). In the case study, the patient has requested confidentiality. The nurse has an obligation of maintaining patient confidentiality. Utilitarisim is a principle of maximizing utility. In nursing care maximum utility is analogous to maximum benefits to the patient. Therefore nurses should take actions that benefit the patient in the long run regardless of short term consequences. In this case study, releasing the patient’s health record to the family would enable the patient to get health care and although it would be a bleach of confidentiality, it is the right action on the long run.
Virtue ethics is the other ethical model applied in nursing practice. It is based on personal character. While deontology is based on duties and obligations and utilitarisim is based on the consequences of an action, virtue ethics advocates for analysis of ethical decisions based on what the action one takes tells about their character and morals (Holland, 2010). From this theory, the nurse should not release the patient’s records since this passes her as a nurse with low moral character. Moral particularisim disregards the concept of moral principles and advocates for the consideration of a case “ as is.” This is on the recognition of shortcomings of other theories which assume there is one right strategy that can be applied to all ethical decisions (Bastable, 2010). Ethical theories are important in nursing practice because they are applied to resolve ethical conflicts.
Confidentiality is an ethical principle that limits the information health providers can share regarding patient care. Confidentiality is the basis of trust since patients are able to freely share information with the health provider with confidence that it will not be released to outsiders. The information covered by confidentiality includes medical history, diagnostic results, treatment schedule and any other information collected from the patient during the provision of care. The information is exempt from the provisions of Freedom of Information Act of 2000 and is subject to HIPAA. In the case study, the patient requests her doctor and nurse to keep the result of her medical diagnosis confidential and not to share it with her husband and mother in law. Dr. J asks for the patients electronic records under the instructions of the patient’s husband. In this case, the ethical issue is that releasing the medical records would be a bleach of patient confidentiality. On the other hand, since the patient has refused further treatment, invoking her family may enable her to get moral support to seek treatment.
Although the concept of confidentiality is legally binding, there are limitations to patient confidentiality. Common situations that lead to breaking patient confidentiality include abuse of minors or dependent adults, intent to commit a suicide or homicide, court orders and for emergency care (Hodgson, Mendenhall & Lamson, 2013). These reasonable limits to confidentiality enhance care delivery and resolve legal dilemmas which may arise in nursing care. In this case, reasonable limitations highlighted above do not apply. However, Dr. J may use the information released to him to further enhance Mrs. Z’s care. This is not a reasonable ground to break patient confidentiality since Mrs. Z is not seeking emergency care. There are other methods that can be used to get Mrs. Z to speak to her family when she is ready and to access timely medical care. Based on this, there is no reasonable basis to break patient confidentiality.
Influence of Culture on Values and Ethics
Culture plays a critical role in the society. Different cultures have different values. For instance, in some cultures decision making is reserved for the family patriarch while in other cultures decision making is an individual endeavor. Cultural values determine what is right and what is wrong in that culture. For nurses to provide patient centered care there is a need for cultural balance (Chambers, Thomson & Narayanasamy, 2012). Nurses should understand the patient culture in terms of understanding life process, health and illness, health care delivery, health maintenance and decision making. Incorporation of cultural knowledge into nursing practice is important because globalization has integrated different cultures. Cultural awareness makes a nurse sensitive to the patients need.
The nurse’s culture is based on individual patient autonomy where the patient has a right to make decisions. In the case study, the patient’s culture recognizes the man as the decision maker and the mother in law as the final authority in housekeeping issues. Mrs. Z adheres to this culture and even consulted her mother in law first when she noted a lump in her breast. Therefore, the husband has sole decision making power over access to the wife’s medical health records. However giving the husband access to these records would break patient confidentiality and is contrary to the principle of patient autonomy (Entwistle et al., 2010). Patient autonomy gives patients who are in the right state of mind the freedom to make informed decisions regarding their care free of control form other people. Nurses have a duty to create conditions suitable for patient autonomy. The most basic condition is patient education of various treatment options and their associated risks. Mrs. Z made an informed decision to keep her diagnosis from her husband and mother in law. Depending on the ethical theory adopted, breaking patient confidentiality would be recommended or not. Patient counseling can encourage the patient to share her medical condition with the family thereby resolving the conflict of breaking patient confidentiality.
Ethical Decision Making Model
Ethical decision making models are used to resolve ethical dilemma. The first step is identifying the ethical issue which in our case study is breaking patient confidentiality based on cultural values. The concepts involved in this dilemma include truth telling, patient autonomy and confidentiality and their identification is the second step. The third step is identifying the options available and choosing the most suitable. Based on the deontology model, the question asked is whether Mr. Z has rights to his wife’s medical records an if the nurse has a duty to give him this information. Mrs. Z asked for confidentiality and the nurse has a moral obligation to limit access to the patient’s health records. Therefore the nurse should not release the patient’s health records to the husband without her consent. However in keeping with the nursing principle of beneficence, the nurse should encourage Mrs. Z to share her condition with her family in order to get moral family encouragement to seek further medical care. In resolving the ethical dilemma, with holding the patients information but encouraging her to share her condition with her family and educating her on available treatment option would be the best option.
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