Describe the nature and context of a health care dilemma you have encountered.
The aim of this essay is to examine a health care dilemma which has been encountered in practice, its ethical implications and how this can be resolved in a manner which "safeguards and promotes the interest and well-being" (UKCC, 1992) of the identified patient or client.
Whilst on clinical placement in a nursing home for older people, it was observed that on a regular basis medication was administered covertly, in the patient’s food, without the patient’s consent, for one of the patient’s living in the home. Covert administration of medication is an ethical dilemma.
The study of ethics focuses on action as well as knowledge, whether these actions are good or bad, or right or wrong and the consequences of these actions (Kenworthy et al, 1996). Tschudin (1994) argues that ethics is at the core of nursing practice.
Sletteboe (1997) states that the concept of dilemma is also at the core of everyday nursing practice. According to Sletteboe (1997) there are three uses of the term dilemma: professional, moral and logical dilemmas. A moral dilemma occurs when a decision has to be made where the solutions are unsatisfactory. Moral dilemmas are essentially the same as ethical dilemmas (Sletteboe, 1997).
Davis and Aroskar (1983, cited by Sletteboe, 1997) say that ethical dilemmas are
situations involving conflicting moral claims and give rise to such questions as, what ought I to do? What is the right thing to do? What harm and benefit result from this decision or action?
Thiroux (1980, cited in Tschudin, 1993) outlined five ethical principles, which are applicable to aspects of life. Thiroux (1980, cited by Tschudin, 1993) stated that the first principle was ‘the value of life’, the second principle was ‘goodness or rightness’, following on closely, the third principle of ‘justice or fairness’, the fourth ‘truth telling or honesty’, and the final principle was ‘individual freedom’.
The patient in the nursing home was an elderly gentleman who suffered from dementia. Due to his confusion and agitation that was present at times, he was prescribed a tablet called ‘Risperdal’ (also known as ‘Risperidone’) which is an antipsychotic. The patient concerned refused to take his medication on most occasions, unless coaxed, which tended to be a lengthy process. According to Kumar and Clark (1998) Risperdal is only completely effective if taken regularly for three months and if not can result in prompt relapse.
The UKCC acknowledges that the covert administration of medication is a complex issue that has produced widespread concern. It involves the essential values of patient autonomy and consent to treatment, which are laid out in common law and statute and underpinned by the Human Rights Act 1998 (UKCC, 2001)
Cayton (2000) looked at a study of people with dementia in thirty-four care homes and hospitals that showed that the covert administration of medication (normally hidden in food or drink) was not only routine, but seen as acceptable in some of the homes. The nurses concerned justified their practice as beneficent (doing good). This can be looked at from the ethical theory of Deontology, not concerning themselves with the results of their actions (Kenworthy et al, 2002). In this scenario the results of their actions would be taking away the patient’s choice, respect, dignity and right to consent to treatment (Cayton, 2000). Deontologists are only concerned with motive; acting out of a sense of perceived duty (duty of care), whatever the consequences. The deontological approach would perceive that administering the patient with Risperdal would be in their duty of care, that is to say promote less confusion and agitation for the patient concerned.
The UKCC’s Professional Code of Conduct, which is a set of ethically based statements regarding the value of life, justice, honesty and individual freedom, could be perceived as a model of rule deontology (Kenworthy et al, 2002). The Code of Conduct states that one should "promote and safeguard the interests and well-being of patients"; therefore from the rule deontological point of view administering Risperdal covertly to the patient concerned, the nurses in the nursing home in question, acted from a rule deontological approach, their motive being to act in the best interest of the patient, to promote less agitation and confusion for the patient, irrespective of the consequences of their actions (taking away the patient’s autonomy).
Seedhouse (1988, cited in Kenworthy et al, 2002) argues that autonomy is a quality, a part of being human, being able to make rational choices and being able to act on these choices. When acting from a rule deontological approach, it is sometimes necessary to take away a patient’s autonomy in order to act in the patient’s best interest. In this scenario, it is justified to administer Risperdal to the patient, without his consent, taking away his autonomy, in his best interest (Kenworthy et al 2002).
A conflict arises in the rule deontological approach when two or more rules can conflict. The UKCC Code of Professional Conduct (1992) states that one should
work in an open and collaborative manner with patient’s ... and their families, foster their independence and recognise and respect their involvement in the planning and delivery of care ... recognise and respect the uniqueness and dignity of each patient...
If one administers medication covertly, without the patients’ consent, without discussion with the family, the deontologist would then be breaking the rules. When conflict arises, the rule deontologist must then choose which rule is of most importance (Kenworthy et al, 2002). In the nursing home in question, the nurses did not consult with the patients’ family. As is the very nature of dementia, some patients’ have periods of awareness and lucidity (Walsh, 1997, Kenworthy et al, 2002)) however no attempt was made to assess when the patient was lucid or to ask the patient when he was lucid whether or not he wished take the medicine, which the UKCC (2001) states each nurse should remember and take into account. This breaks the rule of involving the patient in planning his own care; it is not evidence of working openly with the patient and does not treat the patient as unique or respect his dignity.
A utilitarianism approach to this dilemma would look at the consequences of the action, that is to say what would be of the most benefit? (Kenworthy et al, 2002) The consequences of administering Risperdal to the patient would promote less agitation and confusion and take away patient autonomy. The UKCC (2001) states that the administration of medication without the patient’s consent should only be applied if it would save their life or prevent further decline or promote improvement in the patients’ physical or mental health. In this scenario, the Risperdal promotes improvement of the patient’s mental health.
The utilitarianism approach overrides patient autonomy. This can be considered ethical in the short term in order to promote long-term autonomy. For example, administering medication on a regular basis could benefit the patient in the long-term and restore capacity for self-determination later on (Davies et al, 1997).
Davies et al (1997) argue that a patient needs to be competent of rational thought and self-governance to make autonomous decisions. In the scenario the patient was not competent of rational thought most of the time, however some of the time he may have had periods of lucidity, and as this was not assessed adequately, he never had the opportunity to make an autonomous decision. Davies et al (1997) also argues that nursing is moving away from the medical model and that patients are taking a more active part in their nursing care, however the patient identified is not.
The utilitarian approach would look at the consequences of actions, whether these actions are good or bad, right or wrong, and the actions would be morally right if they can be utilized into bringing about the best consequences (Kenworthy et al, 2002). The utililitarian would administer medication covertly, without the patient’s consent, believing it to be morally right and producing the best consequence, that is to say, promoting the mental health of the patient concerned. They would consider overriding patient autonomy as not as important as patient happiness.
In conclusion, where the nurses in the nursing home morally right to administer medication without the patient’s consent? This ethical dilemma is multifaceted and causes many conflicts. On the one hand administering medication without the patient’s consent could be seen as acting in the patients’ best interest and promoting their mental health, and on the other hand the nurse could be robbing the patient of their autonomy, dignity and right to consent to treatment. Neither of the two main ethical theories provides a cut and dried, morally acceptable answer to the dilemma. The deontologist would argue that administering medication covertly could be in the patients’ best interest, conflicting with another rule of deontology that would argue patient autonomy and choice. The utilitarian view would argue towards promoting the patients’ mental health and autonomy. This dilemma could go some way to be being resolved if nursing staff assessed the patient regularly and observed for periods of lucidity in which the situation could be discussed openly with patient, and their family. Clear guidelines need to implemented and well documented, not just a nursing framework but also a legal framework to protect the patient, whose rights and needs require addressing. (Cayton, 2000).
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