Ethics in Nursing: Case Study

Among the five most frequently cited ethical concerns by nurses surveyed in a recent

study in Australia is protecting the dignity and rights of patients (Johnstone,2004: 24). About

24% of the nurses in the survey reported having been directly involved in a patient’s dignity

issue at least once in a year. It is interesting to note that 20.4% of all the respondents had been

directly involved in a human rights issue between one-to-four times a week. Nurses who reported

non-involvement in such ethical issues in the past one year accounted for only 5%. The findings

of this research demonstrate the centrality of ethical issues and in particular issues of human

dignity, respect and rights in the nursing profession. It is in this context that the dilemma in

which Sammy finds himself (in the case described in the task) calls for an in-depth and reflective

analysis. Critical references to the Code of ethics for nurses in Australia prepared by the

Australian Nursing and Midwifery Council (ANMC, 2008) and Ethics and law for the health

professionals (Kerridge et. al.2009) among other selected professional and ethical documents

and perspectives will anchor our analysis of this dilemma, selection of possible solution(s) and

evaluation of the same.

The case in point involves Sammy (a registered nurse) finding himself alone with a

cerebral palsy patient (Margret) in a clinic at six o’clock in the afternoon. Matters complicate

when the patient invites the nurse to a quick meal at the café. She is underweight and hates

eating alone. This kind of predicament may present it self to health workers and it may not be

uncommon. Kerridge et. al. (2009:92) observes that health practitioners may be confronted with

situations with no clear right or wrong solutions. This is what can been called ethical dilemma or
the right vs. right dilemma (Brousseau 1995:20). According to Brousseau, ethical dilemma is the

most difficult to resolve because the two possible solutions both have a clear moral premise but

they are mutually exclusive. This case clearly poses conflicting ethical values. From a superficial

perspective, either decision taken by Sammy is right. He is right if he chooses to accompany the

patient to the café and take lunch together. Similarly, the nurse is right if he declines. Such a

casual treatment of the problem may not yield the very best solution. Citing Johnson and Scot,

Kerridge et. al recommend ‘moral imagination’ as the best way of dealing with such a

complicated problem (qtd. in Kerridge et. al 2009: 92). Moral imagination is the ability to

examine a problem from different perspectives. It leads to more than one solution to any

problem. Kerridge et al (2009:92) provide a Model for Model for Ethical Decision Making. The

seven-step model integrates earlier frameworks and our treatment of Sammy’s dilemma is

modeled along this paradigm.

Theory controls practice. The valuable guidance from the nursing code and the

documents on ethics cited above cannot be overemphasized. It is however crucial for a

theoretical construct to inform the process of ‘moral imagination.’ With the assumption that care-

giving in nursing is a complex process, Fairchild (353) proposes a construct called Nurses’

Ethical Reasoning Skills (NERS) as a theoretical guide for nurses as they confront ethical issues

in clinical practice. The backbone of NERS is a mental activity called metacognition which is a

process in which individuals reflect upon their own thinking processes (Pesut qtd in Fairchild

2010:358). There are simultaneous thinking processes in this framework: reflection, reasoning,

and review (Fairchild 201:358). These three processes occur in both the internal (background)

and external (foreground) contexts of the problem-solving situation. Reflection within the

context of this theory requires a nurse to go into solution seeking process with the mindset of a
nurse. It encompasses minding about the implications of the available options and how they

affect the nurse, the others and the image of the profession in its entirety. Fairchild (2010:359)

believes this type of thinking is the pillar of a nurse as a care-giver. Reasoning in this construct is

dialectical – the forward and backward movement of thoughts along multiple but clearly defined

spheres. Thoughts towards a solution may move along communal vs. individual, short-term vs.

long-term or cost vs. benefit continuums. While reflection provides a professional basis,

reasoning provides a rational basis for selecting an option. Both reflecting and reasoning occurs

in the foreground. The third skill, reviewing, considers the conflicting values in view of the on-

goings in the foreground. As the options guided by reflection concretize into a way forward, they

are constantly reviewed on the basis of what is on the ground. Review may force a compromise

or preference of one value over the other(s). The act at the sharp end of the triangle represents

the resolution of the ethical dilemma.

Having defined the theoretical roadmap to decision-making, let’s subject the reference

case in point to the seven steps of Model for Decision Making. Our singular goal is to reach the

most widely acceptable outcome. Kerridge et al (95) identifies the very first step in their model

as clearly stating the problem. That is the problem is put into perspective and a distinction is

made between ethical issues and other issues which are legal, medical, cultural or social in

nature. In our case is whether Sammy (a nurse) should accept or decline Margaret’s invitation to

a quick meal at a local café. It is about right and wrong; thus, the gist of this problem is basically

ethical. It should, however, be noted that ethical issues, though typically moral, can be complex

and be intertwined with legal, medical and cultural issues. The moral problem here, as stated on

the onset of this paper, is not so much about right vs. wrong but it is about right vs. right. We ask

two moral questions: Is it right for a nurse to be taken out for a meal by a patient. Or, is it right
for a nurse to decline a patient’s invitation to a meal? The problem at hand, therefore, is a moral

dilemma.

The second stage of the model involves getting the facts about the situation. In our case,

it is a regular female patient with a leg wound and cerebral palsy who had come for review and

redressing. She lives alone but hates eating alone; she is also underweight and she invites Sammy

to join her for a quick meal at the local café. Facts about Sammy are that he is a registered male

nurse; he works in a general practice clinic with five general practitioners and two other nurses.

He has complained of hunger in the hearing of the patient. Other facts in the foreground are that

it is late afternoon (1800), that the other seven health workers in the clinic have left and there is

no patient in the waiting bay. The question at hand: should Sammy accept or decline the

invitation? All this information constitutes the foreground in Fairchild’s theory. They will direct

the 3Rs (Reflection, Reasoning and Review) . The fact that Sammy is a registered nurse puts him

under the jurisdiction and scrutiny of the Code of Ethics for Nurses in Australia.

The third level of the model takes us to ethical considerations. It is at this point that the

first R (reflecting) of Fairchild’s theory comes into play. The nurse is obliged to think as a nurse

(self); think about his client (person); think about the immediate and general community; and

consider the work mates and the nursing profession (colleagues). The ethical principles to

consider may take different perspectives depending on the facet of the problem the nurse would

like to give magnify. Should he choose autonomy, Sammy would consider what Margret would

recommend in the circumstances. Should he put the problem on the self vs. others continuum,

Sammy would land into a deeper dilemma. The fifth value in the Code of Ethics for Nurses

(ANMC, 2008: 5) requires nurses to respect self (moral worth and dignity) and others (including

their ethical values). It also requires nurses to be kind to patients by showing simple acts of
gentleness, being considerate and caring. The code envisions that if Sammy chooses to be kind to

Margret, he will bridge the gap of power imbalance created between them by the patient’s

vulnerability (as a result of illness or pain). The moral contradiction arrives when the ‘simple

acts’ of kindness compromise the nurses dignity which is an inalienable right (Aranda and Jones,

2010:249)). The best practice would probably to follow the principle that results into fairness to

as many parties as possible (Kerridge et al 2009:95). Though the major immediate parties in

this context are Sammy and Margaret, there are other parties like Sammy’s colleagues and the

local community at large. Sammy’s action should not rob their clinic a regular client; neither

should it put their clinic disrepute.

The fourth stage requires an examination of the problem from another point of view or

though another theoretical perspective. As the issues at hand continue to come into the

foreground, dialectical reasoning is valuable (Fairchild, 2010: 357).The situation is interpreted to

generate possibilities. Other ethical perspectives are allowed to interrogate this problem. The

main aim of this process is arrive at multiple solutions out of which one is selected as it is or

modified at the very end of the inquiry. Perspectives need move from the concerns of the two

individuals to the merits of the action that will be taken on its own merits. Kidder’s (qtd in

Brouseau, 1995:6 ) calls this the rule-based thinking. This approach does not look at the

consequences of the decision taken but rather sets the standard to be followed in similar

circumstances. It borrows heavily from the work Emmanuel Kant as analyzed by Paton

recommends that our actions should be guided by universal laws (Paton, 1948: 30). Such laws

that guide our actions in a particular instance should be applicable to all rational human beings in

similar circumstances. The validity of Sammy’s decision, in this situation, lies on its own merits.

No references are to be made to neither the parties involved nor its possible outcome. In deciding
whether to decline or accept a patient’s invitation to a meal, the nurse should follow the maxim

that everyone ought to obey. This has been called the deontological perspective or working from

duty (Bergley 2010:2). Sammy’s possibilities from this angle are limited and constrained by the

call of duty. The moral basis of actions stems from the motives that spring from faithful to duty.

The fifth level of analysis is to identify the ethical conflicts: their sources and resolutions.

It is evident that the major source of conflict of ethical issues accrues from the domains

explained by Brouseau (1995:3-5). On the one hand and is the truth vs. loyalty paradigm and on

the other is individual vs. community. Truth vs. loyalty conflict arises from Sammy’s honesty or

integrity against his commitment or responsibility. He is the one who verbalizes his state of

starving to Margaret. Why does he do this in the first place? What does she want her to do? This

declaration of hunger carries subsumes a promise that “If you can do something about it, I will

appreciate. Margaret’s offer is a natural response to Sammy’s implied request. The dilemma,

nevertheless, tests his moral courage to keep the embedded promise or be loyal to his

professional ethics which demands that he acts in a manner that upholds his self-worth and

dignity (ANMC). It follows therefore that should the nurse decline the patient’s offer, his sense

of honesty or integrity would be greatly dented, at least, in the eyes of this particular patient. On

the other hand, if he accepts the offer, the nurse’s moral credentials would be put into disrepute

as stipulated by the fifth schedule of the Code of ethics for nurses in Australia (ANMC, 2008:5).

This value discourages any action of which the nurse may be construed as taking undue

advantage of the patient who is on the lower scale of power imbalance. The best resolution in

this scenario would embarrass neither the patient nor the nurse. This process maps on to the

reviewing phase of theory advanced by Fairchild (2010:357).

 The individual vs. community paradigm pits the ethic of the profession against the ethic

of the community (Furman, 2003: 3-4). According to Furman, the ethic of profession focuses on

the cognitive, affective, moral and spiritual values intrinsic to an individual. These values

transcribe the character of the professional and guides moral and leadership practice. The ethic of

the community sets the moral standards for the individual. The community offers a frame by

which the individual values are adjudicated. A person who works out solutions within this

framework would fit the description of what would traditionally be known as ‘heroic leadership’

(Furman 2003:4). Although heroism may not be the goal of Sammy’s intervention, conformity to

the dictates of the community may force him not to accompany the patient to the eating place.

The timing, gender differences, social status and the client-patient distance may militate against

what the professional ethic may not, in principle, question. The ethic of profession’ on the

grounds of the patient’s low body weight and cerebral palsy would support programs that

mitigate such situations. Sammy’s decision to take quick meal with Margaret if interpreted from

the tail backwards may constitute the distinction made between friendliness and friendship

(Geanellos , 2002:235-245 and Wolf, et al. 1998:).

Though friendliness is superficial while friendship is deep, both were found, in the study,

to replace feelings of dis-ease with those of comfort and belonging. A similar study found

identified supporting the client’s concern, being physically present and eliciting patient’s feelings

to reciprocate as among the gestures the patients used to describe care-giving. It is important that

the clashing ethical interests in nurse care-giving, as in the foregoing, be seen as a result of

plurality of perspective rather than a conflict of values. Perspectives that favor a specific

dimension, say loyalty, would emphasize matters of conformity at the expense of honesty.
 The resolutions that can work out the ethical dilemma diverge at the point of departure

but as more realities and perspectives come into the surface, or ‘foreground’ Fairchild 2010: 357)

a convergence is sought. Several values emerge and are in competition with each other. The

resolutions that need reviewing are evident. Based on the first perspective described in the third

level above, Sammy thinking first and foremost as a nurse should consider declining the offer. It

would result to the greater good. The merits of this decision among other things, establishes

loyalty, it asserts faithfulness to duty, conforms to the ethic of community; it protects the patient

from nominal ‘exploitation’ and by virtue of its inbuilt merits, the decision sets a universal

precedence. Nevertheless, the selection of this ‘right’ decision over the other ‘right’ option is not

without shortcomings. It is bound to embarrass the nurse and negate the rule of autonomy. It

shows that the nurse is selfish, dishonest and uncommitted. The decision may also present the

nurse as uncaring or unfriendly healthcare giver. To mitigate the negative effects of these

demerits especially on the patient, effective communication and dialogue becomes the most

effective tool to midwife an all inclusive resolution. As advocated by Abma,(2008:194), it is

possible to achieve consensus through dialogue. The last section of this paper deals with this.

Kerridge et al model provides for legal considerations and decision making as the last

two processes. The matter at hand may not warrant legal interpretations. However the law

provides for peer review and evaluation of the decisions and episodes nurses undergo in the

course of duty. The main functions of peer review include regulating entry into practice. It

follows that though Sammy’s predicament is not covered a by a specific legal clause save for the

quasi-legal provisions in the departmental documents like the code of ethics and code of

regulations, peer review which is recognized by the law is at hand to evaluate his actions and
recommend measures that may have legal ramifications. The argument is that ethical issues may

not necessarily moral but they may also have legal cleaving.

The final stage of decision making includes selection, execution and recording of the

most appropriate course of action taken. In our case Sammy is advised to decline the offer. Time

is of essence in decision making Monteverde (2009:613). This maxim if applied in life-

threatening situations may save life. However it is prudent practice to expedite any decision in all

facets of care giving. The manner of execution probably presents the most intricate challenge.

Good advice dictates that issues of ethics be handled such that the dignity and self-worth of the

client is upheld if not uplifted. As noted earlier, dignity as a value is inalienable and intrinsic

(Aranda and Jones, 2010:249). The most dignified way of communicating this decision would

leave the patient esteemed as a human being not a lifeless object (Wolf, 1998). Dialoging and

effective communication skills work towards ensuring a dignified execution of the decision

taken. Abma(2008:796) emphasizes that communication with the patient goes beyond sharing

information. They propose an empathetic dialogue in which feelings and emotions count as well.

Margaret should be taken through the delicate process of disclosure. The nurse should open up

and explain that the decision he has taken is in the best interest of both of them and parties they

represent. The negotiation should lead to consensus and it only then the case of ethical question

would rest.

In conclusion, it is incumbent upon nurses to maintain their high moral ground without

losing sight of the patient’s vulnerability to confidence loss and mistrust. The reference case in

question serves to illustrate that the professional and legal documents or standpoints, without

judicious application, are mere ‘ethical quicksand’ (Eileen 2010:769). When patients occupy the

pith of all ethical considerations, ethico-moral obligations of the other players like the nurse, the
nursing fraternity and the community members will rightly fall in place. Ethical dilemmas will

no longer be a source of discomfiture as reported in the outset of this paper. They will instead be

welcome challenges that summon creativity, objectivity and professionalism. It can be

demonstrated that no ethical conflict is without a principle to guide its resolution. Where

amicability proves elusion, dialoguing and whole-hearted negotiation will prove that consensus

works for the greater good of all.

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