Introduction
There are many problems and unclear situations when the opinions of patients and physicians vary in health and nursing care. COVID-19 is one of the latest and most serious contributions to promoting new ethical dilemmas like admission criteria for vulnerable patients and the inability to meet patientsā needs (Chamsi-Pasha et al., 2020; Robert et al., 2020). In this paper, attention will be paid to the case when a 70-year-old man with type 2 diabetes, hypertension, and a positive COVID-19 test refuses hospitalisation regardless of minor breathlessness and a low oxygen saturation level. The patient copes well in isolation and does not want to be separated from his family. However, the healthcare providers who analyse his condition underline the necessity of transferring him to a tertiary hospital. As a result, a conflict of interest and recommendations occurs, questioning the importance of care, medical professionalism, and personal opinions. A model for ethical problem-solving will be developed on the case, the existing Australian laws, moral principles, and consequential ideas to identify a reasonable way forward.
Ethical Problem
In most countries, all competent patients have a right to receive or refuse medical treatment and care. Yet, the presence of such opportunities does not prevent the development of additional ethical, medical, social, cultural, and religious problems. In this case context, the patient understands that he has two serious chronic diseases. Besides, the impact of COVID-19 is vital because the man was positively tested a week ago. On the one hand, the case indicates that the man followed isolation requirements and did not leave his home. On the other hand, no information about other family members who live in the same house is given. Thus, it is challenging to curb the virus outbreak because this family preferred home isolation versus institutional isolation, which could benefit public health (Wilder-Smith et al., 2020). Isolation of one person with COVID-19 can be futile if other individuals who contact the patient do not follow the same rules.
The quality of life or the degree to which people are comfortable and healthy is another significant issue that continues changing due to COVID-19. When a person is diagnosed with COVID-19, the lives of family members are severely affected by the necessity to spend days and nights at hospitals and hope for a better outcome (Shah et al., 2021). Although not all people report medical or social issues related to the virus, their existence is evident. Loneliness in a hospital, the inability to spend more time with a family, and hopelessness because of lockdowns make sick people reject hospitalisation (Hwang et al., 2020; Mofijur et al., 2021). Besides, diabetic patients are already at high risk of depression, and social isolation because of the pandemic may be another challenge to mental health (Sy & Munshi, 2020). Therefore, the value of the ethical problem should not diminish the worth of social and medical issues in this case.
Facts
Examining the personal and cultural biography of the patient allows understanding if similar cases happened before and what solutions could be made. There are three main aspects in the situation, including older adultsā concerns about hospitalisation and treatment, the preference of home isolation during the pandemic, and the worth of family support for patients with chronic diseases. Gregorevic et al. (2021) emphasise that hospitalisation at an early stage is beneficial for older adults because many people remain asymptomatic and professional help can be overdue and ineffective. Older patients are more vulnerable to COVID-19 than other chronic patients, and complications and unintended harms cannot be ignored (Bartholomaeus et al., 2021). Sometimes, age and chronic (incurable) conditions become reasonable explanations for patients with cancer or schizophrenia to refuse care (Dias et al., 2021; OāCionnaith et al., 2021). Therefore, hospital employees develop specific algorithms and consider all ethical principles to support or oppose a refusal of medical treatment (Cheng et al., 2018). Personal interests, positions, and acceptance of reality define patientsā attitudes toward hospitalisation and treatment.
Many older individuals consider social isolation as a chance to avoid unnecessary infection and damage. They use family support and communication to meet their needs and create the necessary comfort and safety. Still, one should remember that about 11% of mild cases could deteriorate in a short period (Wilder-Smith et al., 2020). Besides, family support may be an advantage for a patient but a burden for other family members due to existing school commitments, work duties, and other household responsibilities (Hwang et al., 2020). Communication with the family and their opinions should be considered to understand if hospitalisation with mild COVID-19 symptoms is the best alternative.
Ethical Principles
When a person decides not to follow medical recommendations and refuses treatment even after being diagnosed with COVID-19, a number of ethical problems occur. In many developed and developing countries, patient rights are as important as human rights, and moral principles of autonomy, beneficence, nonmaleficence, and justice should be followed to establish fair relationships (Varkey, 2021). Each principle affects understanding the patientās needs, but the pandemic provokes new ethical challenges and transparent policies in various care aspects (Close et al., 2021; Gebreheat & Teame, 2021). The principle of autonomy is based on the possibility of every adult with a sound mind to make autonomous decisions, set preferences, and determine what to do with his body (Beauchamp & Childress, 2013; Varkey, 2021). In bioethics, respect for the patientās autonomy is supported by the three-condition theory where intentionality, understanding, and non-control provoke autonomous action and obligations in society (Beauchamp & Childress, 2013). Autonomy means free decision-making about treatment when all risks, benefits, and consequences are properly explained.
The principle of beneficence also matters in clinical medicine as people should understand what benefits are obtained or lost due to healthcare providersā procedures. Medical experts are responsible for providing patients with all sorts of services to prevent harm, help people with disabilities, and enhance well-being by using all available resources (Varkey, 2021). Utilitarianism theories are applied to prove that beneficence, together with the principle of utility, supports moral obligations of care providers to benefit their patients (Beauchamp & Childress, 2013). The next principle of nonmaleficence is similar to the previous one, with the necessity to avoid risks and harms in relation to other people (Stone, 2018). In biomedical ethics, physicians are obliged not to kill, cause pain/suffering, incapacitate, offend, and deprive of life goods (Varkey, 2021). Yet, nonmaleficence is never simple because what causes harm to one person may be a benefit to another person.
Finally, there is a principle of seeking fair treatment of justice in medicine. All practitioners have to respect patients and their wishes, offer equal information, and educate (Das & Sil, 2017). The fair-opportunity rule reduces the power of social benefits in medicine following the criteria for distributive justice following personal needs, efforts, and merits (Beauchamp & Childress, 2013). All these principles allow creating professional-patient relationships guided by the rules of veracity, privacy, and confidentiality. As such, patients may expect their care providers to keep their personal information secret, even from family members. However, there are also obligations of veracity when doctors much promote timely, objective, and comprehensive transmission of information (Beauchamp & Childress, 2013). All these rules and moral principles are closely related and complicate decision-making and problem-solving in clinical medicine.
New Perspectives
Depending on stakeholders and their interests, this situation is analysed from another perspective and consequentialist theory to re-evaluate common moral principles. Today, proactive assessment and remote care for older persons are highly recommended to avoid unnecessary contact and get the required medical information (Bianchetti et al., 2020). Family support becomes more important during the pandemic, but it is necessary not to forget about public safety and hospitalisation benefits (Hart et al., 2020). Thus, family members become relevant stakeholders in this situation, in addition to the patient and medical workers. A consequentialist perspective may be applied to understand better participantsā behaviour. According to this theory, the right decision is the one that has the best consequence (Savulescu & Wilkinson, 2019). Consequentialists believe that a correct decision brings happiness to most people (Geppert, 2017). The patientās family members have to be asked about his condition and their readiness to deal with all possible complications. If they have some concerns, additional communication is required immediately because no cases of COVID-related hospitalisation refusal among older adults are officially reported.
Ethical Conflicts
In this case, there are two major ethical problems, and an autonomy-beneficence conflict is one of them. A patient is free to refuse treatment as a part of his autonomous decision. Healthcare providers should demonstrate an act of beneficence to promote autonomy and enough information about this condition. The promotion of well-being as a part of the beneficence principle is impossible when the patient rejects treatment. The resolution is to follow the patientās demand as he has a sound mind, and no other tests prove the opposite.
Another conflict touches upon the questions of autonomy and nonmaleficence. According to Miller and Smith (2021), the COVID-19 era is associated with technological progress and strong informative support. When people access multiple data sources, they put themselves under threat to make false or irrational conclusions. As a result, physicians cannot follow the principle of nonmaleficence and avoid all possible harms to their patients who continue making their free independent decisions. The solution for this conflict is to contact patients distantly and offer helpful information and recommendations.
Legal Aspect
In Australia, several legal concepts could be implemented to guide the management of this case. The Australian Charter of Healthcare Rights describes the rights of citizens when receiving health care. It was recently edited by the Australian Commission on Safety and Quality in Health Care (2020) to underline person-centred care and empower people to participate actively in care processes. Thus, independent decisions made by patients are highly promoted in clinical medicines. In addition, the Australian Law Reform Commission (2014) admits that common law provides all competent adults to accept or refuse medical treatment relying on respect for physical and mental integrity. These two laws prove qual relationships between clinical, ethical, and legal aspects of human life because every solution is based on human free will, autonomy, and competency.
A Way Forward
When the patient is competent and mentally healthy and rejects hospitalisation to manage his mild COVID-19 symptoms, healthcare providers can do nothing to deliver him to a hospital. Ethical viable options include the intention to change his mind and provide information about the consequences of this decision. This approach helps to maintain a balance between all four moral principles in clinical medicine. The patient remains responsible for his decisions, which proves the respect for autonomy. Family support is never ignored because this treatment rejection is made to spend more time with his family. Thus, the justice principle is followed to meet the interests of other parties. Finally, beneficence and nonmaleficence principles are followed when healthcare providers take their duties seriously, explain all aspects of care in the COVID-19 era, and focus on the age of the patient. The resolution of this conflict lies in the necessity to respect what the patient chooses but never neglects direct obligations in distant care. Telehealth is a common solution for many COVID-positive patients, and if all recommendations are followed, there is a chance to predict the development of new complications and observe recovery.
Conclusion
In general, ethical decision-making and problem-solving in clinical methods are never easy to make. Patients have their interests and positions about their conditions, and healthcare providers demonstrate a high level of knowledge to promote public well-being. There are situations like in this case when the diabetic patient refuses treatment and hospitalisation after being diagnosed with COVID-19. Family members are relevant stakeholders who should be properly informed about the patientās condition and potential threats and harms. The consequentialist theory supports the idea of treatment to achieve better outcomes and recover under professional observations. Still, following all ethical principles and considering the situation, the patientās desire to stay at home cannot be ignored. The autonomy-beneficence-nonmaleficence conflict will be resolved if healthcare workers provide the patient with sufficient information on managing COVID-19 symptoms at home.
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