The Main Moral Dilemma Faced by Nurses

The following essay relates to moral dilemmas faced by nursing staff at all levels within a care organisation. Also discussed are the influences of ethics and potential legal implications associated with any decision being made seemingly either on the behalf of an incapacitated patient, or in their best interest. The case study being analysed for the purpose of this essay is that of Nigel, a 70 plus year old male. Nigel has suffered two Cerebrovascular accidents (CVA), which has rendered him unable to fully recognise and understand the situation he is in. 

The CVA’s have also left him with muscle weakness and introduced Dysphagia and has resulted in significant weight loss. These concerns having been identified by the long-term care home staff have resulted in Nigel being admitted in the local NHS general hospital for immediate assessment which has initially concluded the need for nasogastric feeding. 

This is against Nigel’s wishes. Here lies the dilemma being introduced for discussion. As a professional, whatever the decision a nurse makes she should withhold all expected responsibilities from the experience she has gained throughout their training. Consideration will be given to the state of mind of Nigel and his ability to provide consent, the legal implications of applying the nasogastric feeding, the moral principles and the subsequent moral dilemmas faced by all concerned. 

Further under discussion are ways to help mitigate potential pitfalls and what guidance and support is available for those found in these precarious instances. These could well be in published guidelines as in the case of Mersey Care NHS Trust Clinical Guidance Document – SD-G1, and Medicines Management Procedure – MM010. All of which should buttress the legal responsibilities of healthcare professionals. All names have been changed to protect the identity of patient and staff in line with the Nursing & Midwifery Council.

In the situation above the main moral dilemma faced by nurses and other medical professionals is that the patient is denying a treatment that is critical for is health and life. Since it is legal and professional requirement that treatment and intervention should be undertaken after informed consent, which is a critical ethical requirement therefore, it is now a moral dilemma for nurses whether to continue without his permission to save his health and life or vice versa. The ethical principle of informed consent has been widely researched and is interlinked with other ethical principles in nursing profession. A Valid consent is defined as being given by a mentally competent person without any duress or fraud.

According to Griffith and Tengnah, the justification to maintain and observe informed consent is grounded in the fact that the autonomy of the patient must be safeguarded. The autonomy of patients is defined as the capacity of the patient to make independent decisions. The source of the principle of autonomy is linked often with the moral and ethical philosophy of Kant and sometimes with Mill’s philosophy. However, the “principlist” approach of Beauchamp and Childress explains autonomy more comprehensively. 

Furthermore, these principles are commonly shared by all types of societies irrespective of the difference between their religious or social beliefs and behaviours. These are mostly shared by all types of people. Although, the principlist approach is very often cited as the bases of modern health care nursing models, yet there are some critiques that are presented in this approach also.

In case of Nigel, as per the principalist approach, nurses must respect his choices regarding the care he receives. Understanding of his emotions being in an unfamiliar environment would also add to his anxiety, fear, powerless and feeling vunerable, and needs to be accounted for (Dimond,2019). Furthermore, it is critical that the nurses and other professionals provide him sufficient information about his options and choices and their impact on his health and life to enable him to make informed decision.

Furthermore, there is the principle of the beneficence which also presents a dilemma for the professionals involved. The beneficence refers to the care and services in which acts of mercy, kindness, charity, love and humanity are integrated in order to enhance the quality of service and quality of life of patients. These principles also contribute towards development of effective relationship with the patients. In short, it’s a moral obligation to act for the benefit of others. The intervention of nasogastric feeding is aimed ultimately to benefit Nigel however his denial to this intervention presents the conflict for nurses to whether observe the principle of autonomy or the principle of beneficence.

In such a dilemma Sortedahl, Mottern, and Campagna, argued that the patient autonomy and relevant decisions in medical care service are contingent on the ability of the patient being mentally capable to make such a choice. If the patient lacks mental capacity, nurses should follow the code and standard that are relevant for mentally incapable patients that allow decision making in such a moral conflict.

The principal non-maleficence can be defined as minimising harms and balancing benefits against harms Armstrong (2007). In the case study one would be able to accept this principle on the basis that ultimately the benefits obtained by introducing the nasogastric feeder far outweigh the minimal harm inflicted – discomfort of the nasogastric feeder.

Armstrong goes on to state that the principal of non-maleficence would appear to be more weightier than the principal of beneficence adding that it is morally more important to ensure harms are kept to a minimum. Nursing ethics author Armstrong evaluates several approaches with respect to obligation based moral principles consequentialism and Deontology – study of duty and obligation – Hursthouse, 1999. Obligationists are expected to behave in certain ways towards others.

Armstrong adds that consequentialists are described a s forward looking theorists in the sense that if they perform and act which results in a good consequence then that act performed must have been the correct act. In the case of Nigel applying the nasogastric feeding tube against his will is ultimately the correct act as the outcome will without doubt put him in good health.

Throughout all of the bodies for nursing there is continuous reference throughout to “The Code”: Professional Standards of Practice and Behaviour for Nurses and Midwives. The four basic themes of the Code being Prioritising people, Practise effectively, Preserve Safety and Promote professionalism and ultimately trust. The code states that in the interest of preserving Safety nurses must be fully trained and have the necessary education before taking on any further roles and responsibilities. This inherently enables dilemmas as such outlined in the case study to be professionally and accurately addressed by competent qualified personnel. This way it can be assured that Nigel will obtain the best possible outcome taking into account all variables in the assessment of his dilemma.

All of the bodies have their own specific guidelines which define for example within the NMC, there are a set of 9 standards and guides covering the Code, Revalidation, Nurses, Midwives, Nursing Associates and Post-Registration. Along with the standards and guides the governance of the body is clearly outlined with detailed information on their own roles and responsibilities ranging from the regulatory roles to performance and financial reporting being fully available with the public invited to attend the council meetings being held on a frequent basis – 6 times per year.

One of the expectations of a professional is to be responsible for their own development and the means to achieve this would be through maintaining a professional portfolio. Furthermore, the Code states that for a Nurse to continue to practice safely and effectively they need to maintain a certain level of knowledge and skills and be able to demonstrate such including providing reflection of risks observed and how they have been managed and documented for ease of future reference for self and colleagues.

It is important to mention that as per the Mental Capacity Act 2005 it is a professional requirement that a decision made for a patient must ensure compliance with the principle of ‘best interests’. Broadly, best interest is defined as that professional should not assume on the basis of appearance, age, behaviour or condition. Furthermore, the patient has the right to make advanced decisions to refuse treatment also called the living wills. This must be followed by nurses provided that it is applicable and valid, even if following the refusal causes the death of the patient. The incorporation of best interest principle requires professionals to comply with treatment preferences and advance decisions.

In case of Nigel, currently professionals must decide whether they must comply with his wish to undertake feeding intervention or not. As per the professional requirement, the professionals must follow his instruction and respect his denial provided that he shows that he has the mental capacity to undertake this decision.

In addition to moral and ethical conflicts and dilemmas, nurses may also encounter legal issues while dealing with patients such as Nigel. The legal aspect of any medical decision has far reaching implications. As outlined by Terry et al the professional legal responsibilities are also linked to other colleague responsibilities as well as the healthcare organisation they are employed by and by external governing rules and regulations. Some of the legal frameworks applied in the UK are derived from the Tort law and its principles which relate to the laws of causing harm or damage to other person. 

According to Scott, the fundamental principle that underlie the legal requirements and duties of medical professionals is the non-maleficence, i.e. do not harm to the patients. This legal duty is grounded in the ethical principle of beneficence discussed above. Within the context of nursing and medical professional in general the most common issue is the avoidance of negligence claims. Medical negligence causing harm to patients occur when a professional fails to follow standard of care and consequently patient(s) may face injury or arm of any kind.

In case of Nigel, the issue arises when nurses know that the feeding intervention is critical and rather essential for his life and health but his denial makes it difficult for them to make decision. On the one hand, if nurses refrain from the intervention to maintain autonomy and gain informed consent, they are at risk of compromising his life and health. On the other hand, they are legally obligated to ensure non-maleficence and prevent any decision that may cause harm. Refraining from feeding intervention may cause harm to Nigel and ultimately the professionals are at risk of being sued or litigated for medical negligence. Therefore, nurses need to follow standard of care and relevant models in this situation to prevent negligence claim and also maintain ethical principles.

In the UK and Wales, there is The Mental Capacity Act 2005 that establishes a statutory framework regarding patients who lack capacity and are unable to make decisions. This Act provides a code of practice for any person who is working with or caring for a person who lacks mental capacity for medical decision making. As per this code of ethics nurses must assume that the patient has mental capacity until it is established that he lacks.

It is clear that in this case, the professionals first need to assess the mental health and capacity of Nigel. The aim is to assess whether he is legally capable to undertake his medical care decisions. The capacity assessment test as defined in the Act to have two stages. First the nurses have to assess if Nigel is facing any impairment of minds and brain that may deteriorate his ability to understand and analyse facts and information. The second element of the assessment is if there is any impairment, whether Nigel can make right and sound decision life a reasonable man would while having the impairment. Ultimately the aim of assess whether the in case the assessment shows that he lacks the capacity.

From the onset of the essay it has never been the intention to find a resolution to the ethical and moral dilemma identified in the case study of Nigel. The essay has focused on identifying the dilemmas and what considerations should to be taken into account when analysing. The essay has identified several key areas that a nursing practitioner and indeed a student nurse should be aware of. These key areas focus on required training not only on identifying dilemmas but ultimately understanding the moral legal aspect of any decisions that they make. Fundamentally the main key message is the welfare and being of the patient and their rights to autonomy. 

The essay has identified there are adequate resources available for guidance in all aspects of ethical and moral dilemma identification and how one approaches the gain resolution of the dilemma through Professional bodies such as BMA, NMC and RCN. Notwithstanding there is also great emphasis on the individual applying the ethical codes of professional conduct which they have been made aware of and in fact signed up for during their training and formal registration. Continuous feedback by the professional back into their organisation will ensure that the applicable code of ethics and respective regulations evolve accordingly as the needs arise.