“The ability to show strength of character through compassion leads the list of employee responsibilities. It is health care workers that hold in their hands the gift to be instruments in the healing process. Compassionate caregivers make the difference in the life of both patients and co-workers. It is the compassionate caregiver who guides the patient as he or she struggles through illness, pain, and suffering. It is the compassionate caregiver that provides hope when there seems to be no hope.” (Pozgar, 2005)
As health care providers, neurologists are expected to follow a code of ethics as they provide care for their patients. However, how regularly do we actually consider what this actually entails? During my residency, I encountered a patient’s case which brought up a series of ethical issues.
In this case study on ethics I will explore the implications of Beauchamp and Childress’ Four Principles framework. These principles provide the framework which may facilitate individuals and society to resolve conflict in a fair, just and moral manner.
PRESENTATION AND HISTORY
A 45-year-old woman presented with complaints of a low-grade fever accompanied by headache and nasal discharge of two months’ duration. She had been diabetic for 4 to 5 years and had poor glycaemic control. She developed redness and swelling over her nose for which she was started on antibiotics outside; there was no response so she was referred to us.
On admission she was febrile, had facial puffiness, right-sided periorbital oedema, right-sided sixth cranial nerve palsy and nasal twang because of a perforation of the hard palate. Investigations revealed anemia and uncontrolled blood sugar. Smear of nasal swab revealed fungal hyphae, which was found to be aseptate hyphae of mucormycosis on histopathological examination. She needs IV Amphotericin-B with insulin therapy and debridement of sinuses under general anesthesia.
Patient had indicated quite clearly that she did not want treatment. She was uncomfortable in a hospital setting and was frightened of needles.
I stressed the importance of medical management to the patient, and the consequences that were likely to arise due to poor compliance to proposed treatment plan, or any deviation thereof.
I did everything in my power to attend patient’s concerns and misconceptions regarding medical management. After presenting my rationale for treatment again, patient agreed.
During her stay in the hospital she began to improve and was subsequently discharged.
ETHICAL PRINCIPLES AT PLAY
This case example looks at the ethical principles of beneficence, nonmaleficence, justice,
and patient autonomy. These principles are taken into consideration each day by health
care providers as they make decisions on how to best meet the needs of their patients.
Principle of Beneficence
Beneficence is action that is done for the benefit of others .A group of norms for providing benefits and balancing benefits against risk and costs.
The healthcare professional should act to benefit his/her patient. This principle may clash with the principle of respect for autonomy when the patient makes a decision that the healthcare professional does not think will benefit the patient – is not in her best interests.
The principle of beneficence is centered on the idea of helping and doing good to others. It encompasses the qualities of compassion and showing kindness to everyone despite circumstances. This quality is shown as practitioner’s provide health care benefits to their patients in the form of treatment protocols. It is also seen in the decision making of balancing well versus the potential side effects that can come from treatments. Within the principle of beneficence is the related principle of Paternalism. This idea centers on the practitioner trying to make decisions for the patient that they believe will best help the patient.
In this case we should consider both the long term and short -term effects of overriding patient’s views. In the short – term patient will be frightened to have a needle inserted in her arm and to be in hospital – this may lead her to distrust healthcare professionals in the future and to be reluctant to seek medical help. In the long term there will be a benefit to patient in having her autonomy overridden on this occasion. Without treatment she will suffer serious and long-term health problems that would require greater medical intervention than the treatment required now.
The benefits of acting beneficently would need to be weighed against the dis-benefits of failing to respect patient’s autonomy.
Principle of Nonmaleficence
Non-maleficence means to “do no harm’ It is a norm of avoiding the causation of harm. It asserts an obligation not to inflict harm on others .It is probably the most mentioned ethical principle regarding health care.
It teaches us about not bringing harm to our patients. It is based on the avoidance of
causing pain and discomfort to those whom we treat. Harm to a patient can be physical,
emotional, or psychological. In the case study, I didn’t want to subject or force this
patient. Physicians should not provide ineffective treatments to patients as these offer risk with no possibility of benefit and thus have a chance of harming patients. In this case I tried my best to convince her about recommended treatment.
The principle that deals with fairness, equity and equality and provides for an individual to claim that to which they are entitled. All patients should be treated fairly and be given an equal value of care when in the same circumstance. Justice in health care is usually defined as a form of fairness, or as Aristotle once said, “Giving to each that which is his due.”
In this case I offer her best treatment option for her disease.
Respect for autonomy:
The right to participate in and decide on a course of action without undue influence. A norm of respecting the decision making capacities of autonomous persons.
The principle of respect for autonomy entails taking into account and giving consideration to the patient’s views on his/ her treatment. Autonomy is not an all or nothing concept. Patient may not be fully autonomous but this does not mean that ethically her views should not be considered and respected as far a possible. She had expressed her wishes clearly; she did not want a needle inserted for the injections. An autonomous decision does not have to be the ‘correct’ decision from objective viewpoint otherwise individual needs and values would not be respected. However an autonomous decision is one that is informed – has patient been given enough information, in a manner that she can comprehend? Yes as in our case.
“How far you go in life depends on you being tender with the young, compassionate with the aged, sympathetic with the striving and tolerant of the weak and strong. Because someday your life will have been all of these.”