Nicole Schneider & Carly Schreiber
Professor Kirk, Biomedical Ethics
Argument Essay Assignment
A patient presents with an arm fracture and admits to the assisting nurse that it is due to intimate partner violence. However, the patient asks the nurse to neither document nor tell the attending physician the real cause of her injury. This request for nondisclosure prevents further examination of the patient for other injuries that may be present from the violence, and thus the necessary treatment.
The ethical dilemma here is whether the patient’s confidentiality and request not to disclose the true source of her injury should be respected, or whether the intimate partner violence should be disclosed in order to efficiently examine and treat the patient, and possibly prevent future harm.
Two ethical principles that are relevant in addressing this ethical question are autonomy and beneficence. These principles are applicable in that the case is largely a matter of respecting patient autonomy, and weighing the benefits and harms from the course of action taken. Autonomy outlines an individual’s right to participate in decisions regarding their health care. The elements of autonomy include free action, effective deliberation, autonomy authenticity and moral reflection. These subcategories include the individual’s right to choose and make their own decisions, reason capably and rationally about their medical situation, align the choice of action with their character and values, and their ability to reflect on those values (1). Beneficence is an ethical principle that advocates for orientation toward the good of the patient, and also includes several subcategories that help define it. Beneficence includes acting to benefit a patient psychosocially, physically and emotionally, not just intending good but doing good, balancing possible harms and benefits in a ratio whereby the benefits outweigh the harms, and focusing on the benefits the individual patient would receive as opposed to the greater society (2).
Regarding the ethical question of whether the intimate partner violence should be disclosed, we believe that the nurse should not disclose this information, thereby respecting the patient’s autonomy and beneficence.
Both autonomy and beneficence justify the course of action of nondisclosure. Within autonomy, all four elements can be used to explain why nondisclosure would respect the patient and her decision. There is no reason to believe the patient doesn’t have decision-making capacity. Even if a full examination and possible treatment cannot be administered, it is the choice and therefore free action of the patient to decide what is best for her regarding her medical care. It’s possible that the she may not be able to reason rationally or make decisions in line with her desired outcome. However, the patient presented with a fractured arm, and at this point there appears to be no sign that she is irrational or incompetent in decision-making, thus we cannot assume the opposite. Furthermore, it’s very possible that her decision does align with her desired outcome, such as avoiding being shunned for speaking out, waiting until she’s prepared for the consequences of disclosure, avoiding putting herself or her children in more danger, or even a desire to stay with her partner despite the violence. Whether the clinician agrees with her decision or not is irrelevant with respect to patient autonomy, and the nurse must act according to her wishes. We don’t have enough information regarding any moral reflection between her values and decision to determine whether they align or not. However, based on the patient’s decision-making capacity, there’s no reason to believe that upon reflection, her decision would not align with her character and desired outcome. Therefore, not disclosing the information to the physician or in documentation would respect patient autonomy.
Additionally, respecting the patient’s wishes aligns with beneficence for a number of reasons. Beneficence refers to orientation toward the good of the patient. Specifically, this means choosing a course of action that benefits the patient’s physical and psychosocial wellbeing. In this case, respecting the patient’s wishes would provide significant psychosocial benefit for the patient, in that the patient would feel relief and take comfort in knowing her wishes regarding her personal life are being heard and respected. Although she faces difficult challenges at home, simply respecting her wishes outside her home would provide her with some sense of control even during a time of extreme vulnerability. Another important benefit of respecting her wishes is that this would maintain and strengthen the trust and rapport established between her and her clinicians. This would likely make her less fearful about disclosing personal information to healthcare professionals in general and in the future, giving her an outlet to address sensitive concerns and difficult conversations with professionals she trusts. This would further benefit her psychosocially and possibly physically in the long term. Beneficence is also related to the principle of non-maleficence, which means minimizing or preventing harm. In this case, nondisclosure would prevent the psychological harm the patient might experience if she felt her confidentiality was violated by her clinician. Disclosing the violence would also cause the patient more more psychological distress, by forcing her to deal with the consequences that would follow, even though she may not be ready or equipped to handle them. Therefore, nondisclosure prevents these harms and aligns with non-maleficence.
One counterargument to acknowledge is that nondisclosure might enable the abuse to persist. Without proper intervention from the physician and other professionals, the patient might get abused again and be at further risk for serious physical injury.
Although the counterargument mentioned is strong, the ways in which the ethical principles of autonomy and beneficence support the notion to respect the patient’s wishes make nondisclosure in this case more justifiable. Although nondisclosure might pose a physical risk, beneficence accounts for the psychological and emotional wellbeing of the patient. As mentioned above, going against the patient’s wishes would create even greater psychological distress for the patient, dissipate the trust built between the patient and the clinician, and likely make the patient more reluctant to open up to other clinicians in the future, which could harm the patient in the long term. However, respecting the patient’s wishes would benefit the patient, in that it would give her a sense of control over her medical care, and would enhance the trust formed between her and her practitioners. With respect to autonomy, the patient’s right to decide on her care should be upheld regardless of the nurse’s concerns or opinions, since the patient does not lack the capacity to make such decisions, as explained above.
The ethical principles of autonomy and beneficence not only support the notion to respect the patient’s wishes, but also provide a stronger argument for nondisclosure than the alternative. Since beneficence refers to an orientation toward the good of the patient, and acting to benefit the patient while minimizing harm, the psychosocial benefits of nondisclosure make this course of action ethically supported. This course of action is also supported by the patient’s right to autonomy, which requires a clinician to respect the patient’s wishes regarding her care, including the patient’s wish to not disclose the true cause of her injury to the physician. Since the patient has a right to free action, and there is no evidence that she lacks effective deliberation, autonomy authenticity, or moral deliberation, we must respect her right to freely make these decisions about her care by respecting her wishes. Although the alternative course of action assesses for the potential physical harm that might result from nondisclosure, the ways in which autonomy and beneficence assess the patient’s rights, and other potential benefits and harms, make nondisclosure a more ethically justified course of action.
References:
(1) Yeo, M et al. (2010). “Autonomy.” In M Yeo et al. (eds.). Concepts and Cases in Nursing Ethics. [3rd edition] Ontario: Broadview Press, pp. 91-97, 103-109.
(2) 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.
