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Biomedical Ethics

Ethical Argument Essay

“Jenkins (2006) presents a case in which a patient presents with an arm fracture due to a fall, but then privately discloses to the nurse that the injury is due to intimate partner violence. The patient asks the nurse (Jenkins) to (a) not document the true cause of the injury and (b) not inform the attending physician of the violence incident, thereby also refusing examination/treatment of any other injuries sustained during the incident. In retrospectively analyzing the care encounter, Jenkins frames her ethical dilemma as one between (i) respecting the patient’s confidentiality and (ii) maximizing benefit/preventing further harm to the patient and the patient’s children. (Jenkins.)

Ethics consultation is requested for guidance on whether to respect the patient’s request for nondisclosure of the true cause of the injury or to document and disclose this information to the attending physician thereby respecting the patient’s confidentiality. We recommend Jenkins not document and disclose the true origin of the patient’s injury consistent with the principles of beneficence and respect for autonomy.

Beneficence is an obligation to promote the good of the patient while minimizing the preventable harms (Yeo, et al. Beneficence). Benefits are established clinically by Nurse Jenkins and non-clinically by the patient. Evaluation of benefits and harms is determined collaboratively with the patient and is consistent with the patient’s goals of care. The patient’s goals are stated: nondisclosure of the true origin of the patient’s injury. Benefits are therefore defined as processes and results in alignment with this outcome (Yeo, et al. Beneficence). Harms are defined as processes and results inconsistent with this outcome (Yeo, et al. Beneficence). Nurse Jenkins did not accept these goals of care and through discussion convinced the patient to consent to disclosure of the true origin of the injury (Jenkins). The source of conflict appears to be in comparing the benefits and harms of each option to the patient and her children.

At this point the patient prioritizes her privacy over full disclosure, and is willing to accept the possibility of injuries going unexamined and untreated as an acceptable risk. Nurse Jenkins however prioritizes full disclosure over maintaining discretion and confidentiality (Jenkins). Nurse Jenkins recognizes this is inconsistent with the patient’s goal of nondisclosure. Confidentiality, defined as maintaining the patient’s privacy to maintain trust and the therapeutic relationship between the patient and provider, is also at stake (Kirk, Confidentiality). Consistent with the principle of beneficence, nonmaleficence, or the minimization of preventable harm, Nurse Jenkins clinically dictates that disclosure would potentially protect the patient in the event of a future episode of domestic violence by establishing a record of the pattern of abuse at the expense of the patient’s confidence. Nonclinically, nonmaleficence dictates disclosure exposes the patient to the preventable risk of escalated violence to her and her children, and maintains the therapeutic expectation of confidence. Both positions are reasonable because the facts of the situation are agreed upon by both the patient and Nurse Jenkins. To answer this questions satisfactorily we need to also examine the implications of another ethical principle: autonomy, specifically, autonomy as 1) free action, as 2) effective deliberation, and as 3) moral reflection (Yeo, et al. Autonomy).

Respecting autonomy is an obligation to allow the patient to make their own decisions regarding their healthcare and treatment (Yeo, et al. Autonomy). Autonomy as free action (1), similar to liberty, indicates the patient can do as they wish, or will not be coerced by circumstance, or another person, into doing something they do not want to do (Yeo, et al. Autonomy). Similarly Autonomy as moral reflection (3) denotes the patient has made a conscious, self-reflective choice that is consistent with their personal values. Autonomy defined as such also demands effective deliberation (2)–the ability to come to a reasonable, logical decision based on the information available (Yeo, et al. Autonomy). Autonomous decisions are to be respected by the clinician unless they violate another, relevant ethical principle. In this case the patient’s ability to make decisions is not in question (Yeo, et al. Autonomy). The patient understands all the options available to her and their likely consequences (Jenkins). Reflective of autonomy as moral reflection her preferences are consistent with her stated values and goals (Jenkins). The patient is explicit in the fact that her values informed her choice for nondisclosure. Respecting autonomy in this case therefore requires Nurse Jenkins to maintain the patient’s confidentiality and not disclose the true origin of the injury.

Some may argue that it is an obligation to beneficence to disclose this information so that it can be documented appropriately. Historically domestic violence escalates, and the patient is at an increased risk for continued and worsening injuries (Smith, et al.). Documentation would be important to potentially file a police report necessary to obtain an order of protection, if the patient decides she wants to leave or realizes her life is in danger. Documentation would also be consistent with beneficence in ensuring the patient can be more thoroughly evaluated by her physician during her physical exam so that no other injuries go untreated.

While the options discussed both have benefits and harms associated, the likelihood of harm consistent with the goals of care associated with disclosure appear much greater than the likelihood of benefit/reduced harm. There is both benefit and risk of harm associated with non-disclosure. In terms of beneficence, respecting the patient’s request for confidentiality presents a superior benefit/harm ratio when compared to disclosure. Respect the patient’s autonomous choice for confidentiality and non-documentation/disclosure is strongly supported by an obligation to respect her autonomy and beneficence compatible with her stated preference for nondisclosure, despite the risk of domestic violence escalation and other untreated injuries.

Essentially, we recommend that Jenkins maintain the patient’s confidentiality and honor her request for non-documentation/non-disclosure based on the principles of beneficence and respect for autonomy.

References
Aris, R. (2018). Escalation. National Domestic Violence Hotline.
https://www.thehotline.org/2018/09/28/escalation/

Jenkin, A, Millward, J. (2006). A moral dilemma in the emergency room: Confidentiality and domestic
violence.Accident and Emergency Nursing, 14(1), 38-42.

Kirk, TW, (2014). Staying at home: Risk, accommodation, and ethics in hospice care. Journal of Hospice
and Palliative Nursing, 16(4), 200-205.

Kirk, TW. (2015). Confidentiality. In N Cherny, M Fallon, S Kaasa, R Portenoy, & D Currow
(eds.). Oxford Textbook of Palliative Medicine. (5th ed.) New York/London: Oxford University Press, pp. 279-284.

Smith, M, Segal, J. (2019). Domestic violence and abuse. HelpGuide: your trusted guide to mental health
& wellness. Harvard Health Publishing of Harvard Medical School.
https://www.helpguide.org/articles/abuse/domestic-violence-and-abuse.htm

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.

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.

Reflection Paper

In this essay I will explain why I have chosen to become a physician assistant and how the aspects of being a practicing physician assistant that are most important to me are in line with the ethical values of beneficence and autonomy.

            I have always known I was going to go into the medical field. From a young age, I always wanted to help people. I also loved medicine and the human body. I knew PAs were trained similarly to doctors, but with extensive training on interviewing, counseling and patient-centered care. I wanted to take care of patients and put their needs at the center of their care. I thought that the best way I could do this compassionately was as a PA. I further confirmed this with shadowing of PA’s. Their knowledge of medicine was extensive, and they exuded professionalism and compassion for patients. I wanted to be that caring, compassionate, provider who challenges herself daily to learn more about medicine for my patients.

            There are several aspects of clinical practice that will be important to me. One of those is to be a clinical guide for patients while adhering to the patient’s goals and fixing the problems that they perceive as problems, not just ones that medicine clinically dictates. For example, I will listen to and believe women when they talk about menstrual pain and do my best to reduce that pain using my clinical knowledge. Additionally, I find it important to educate patients about their health, including how they can take care of themselves at home, what activities and foods, are good for their and what activities and foods are bad for them that they may not have known before. This can be applicable widely to many fields of medicine, so no matter what area I choose after graduation, I will be able to practice clinically with these aspects that are important to me.

            The two ethical principles that will guide my practice are beneficence and autonomy. Beneficence, as discussed by Yeo et al., dictates that someone who acts with beneficence acts to promote good and to prevent harms. In healthcare, the person acting with beneficence is the clinician and the actions are dedicated toward helping the patient. This can take many forms, whether it be providing lifesaving, comfort-oriented procedures, or by refraining from care practices that will harm the patient. Care that is good for the patient can be defined by both the patient and the clinician. (Yeo, et al.) Beneficence aligns with the aspects of care I find important. I want to provide care for patients that helps them not only clinically, but also psychosocially. An important benefit I can give to my patients is listening to their goals of care and adhering to those goals when coming up with a treatment plan that benefits them according to their goals and my clinical goals. Additionally, providing education for patients allows them to take care of themselves better in ways that they may not have been aware were available to them. When patients are aware of the ways they can benefit their health at home whether it be the correct way to take a medication, suggestions of how to be more active, or that taking care of their teeth can improve their overall health, it is the first step to actions that will benefit their health. It is important to me to take this time to educate patients so that they can benefit from improved understanding of their health. 

The second ethical principle, patient autonomy, can be looked at from four aspects. The first is autonomy as free action, that patients have the right to make decisions about their care. The second is autonomy as effective deliberation, where the clinician contributes to a situation where patients can logically come to decisions regarding their care. The third is autonomy as authenticity, where the patient makes a decision that aligns with their values. Finally, autonomy as moral reflection, where the clinician helps the patient think about the values they want to guide their decision. All four aspects of autonomy can be combined to guide a clinician to provide autonomous practice. (Yeo, et al. Autonomy). Recognizing that patients have their own goals of care that align with their values and adhering to these goals means I will be practicing in line with patient autonomy. Including patients in the decision in how care is to be provided acknowledges that patients have the right to make decisions about their care based on what is most important to them. By listening to patients and including them in the decision making, I will be helping patients to deliberate about their goals as well as bring their values that guide their decisions to the forefront. Additionally, when educating patients, I am providing them with the ability to make autonomous decisions. Without understanding a full profile of benefits and harms, patients cannot effectively deliberate or make decisions based on their values. Without educating patients, I would not be practicing with patient autonomy. Furthermore, by providing patients with education I would be giving them the tools to make educated decisions about their care that can be widely applicable to making immediate clinical decisions as well as making changes at home to better take care of themselves. 

            In this essay I have shown why I want to be a physician assistant. I have explained that the most important aspects of clinical practice to me are in line with the ethical principles of beneficence and autonomy. 

Sources: 

Yeo, et al. “Beneficence.” In M Yeo et al. (eds.). Concepts and Cases in Nursing Ethics. [3rd edition] Ontario: Broadview Press, pp. 103-139.

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.

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