Background Information
The movie “Wit” was written by Margaret Edson in 1998. The movie is basically about a fifty-year old woman who was a professor of English specializing in 17th century poet, John Donne. The woman referred in the film as Dr. Vivian Blearing was diagnosed with stage 4 ovarian cancer. Following the diagnosis, Vivian was assigned to Dr. Kelekian and his fellow Jason, who happened to be Vivian’s student during his undergraduate. The movie revolves around Vivian, Dr. Kelekian, Jason, Susan (Vivian’s primary nurse) and several technicians. It is also intertwined by several scenes in which Vivian makes reference to her teaching career and her experiences with her students.
The movie is of significance to the medical and nursing worlds because it illustrates the relationship between a patient and healthcare practitioners. The central theme of the movie is the conflict of interest that most healthcare professionals encounter. In particular, the healthcare practitioners in this movie are charged with the responsibility of treating Vivian but instead Vivian becomes an object of experimentation for their research (Kent, 2001). A number of ethical and legal issues are evident in the movie and these issues are the subject of this paper. This paper examines in depth the ethical and legal issues that have been raised in the movie. It also discusses the effect of the unethical and illegal practices as well as the strategies that can be taken to avoid them.
Ethical Issues Identified in the Movie
Autonomy
Potter and Perry (2010) argue that “the principle of autonomy is based on the assertion that individuals have the right to determine their own actions and the freedom to make their own decisions” (p. 119). Respect for the individual is the keystone of this principle. Autonomous decisions are based on: individuals’ values, adequate information, freedom from coercion and reason and deliberation. Examples of autonomy in the healthcare include: refusing treatment, giving consent for treatment or procedures, and obtaining information regarding results of tests and treatment options (Potter & Perry, 2010).
Autonomy is highly disregarded in the movie “Wit.” The patient Vivian lacked the autonomy to make the right decisions. The doctors made all the decisions on her behalf. The decisions included the type of treatments to give her, the frequency of the treatments, and the decision to resuscitate or not to resuscitate. Vivian was not in a position to make the right decisions concerning her treatments because she lacked adequate information about her condition. The doctors knew that the doses of chemotherapy they were giving Vivian not only failed to cure her but also failed to remit the illness. Yet they continued with the treatments. They also failed to disclose this information to Vivian yet the information would have enabled her to decide whether or not to continue with the treatment.
Beneficence
Beneficence is commonly defined as the doing of good and is often thought to be the most critical ethical principle in health care (Potter & Perry, 2010). Fundamentally, the principle requires one to always consider his actions in the context of enhancing the welfare of the patient. This however becomes a challenge when what is generally considered to be good for the patient also brings harm to the patient or conflicts with the patient’s desire. Beneficence in the movie “Wit” is illustrated through Susan, the registered nurse who is in charge of Vivian. Susan is the only healthcare professional in the hospital who is concerned about the welfare of Vivian.
She is not only Vivian’s care giver but also her advocate. Many times, Susan disagreed with the doctors treating Vivian on the progress of Vivian’s condition and the treatments the doctors were giving her. She advocated for Vivian’s wellbeing by forcing the doctors to manage the side effects Vivian was experiencing from the chemotherapy. In addition, she advised Vivian’s physicians to reduce the dosage of chemotherapy they giving her due to the negative effects the chemotherapy was having on her.
The first instance of this type of advocacy occurs when Susan tells Jason, Dr. Kelekian’s fellow, to ask Dr. Kelekian to reduce the dosage after Vivian went back to the hospital due to fever and neutrophia (Edson, 2002, p. 44-45). Unfortunately Jason could hear none of it and argued that Vivian was strong enough to bear the full dosage. Susan also showed beneficence by informing Vivian on what was going on with the treatments she was getting and the prognosis given by the doctors.
Based on the information, Susan helped Vivian to make a decision that was beneficial to her. This is illustrated at the end of the film when Susan stopped the resuscitation efforts of the code team in honor of Vivian’s decision. Vivian had decided not to be resuscitated yet the doctors were insisting on the resuscitation for the sake of the research. The lack of beneficence on the other hand is portrayed by Vivian’s doctors who were more interested in their research efforts than on Vivian’s recovery and wellbeing.
Nonmaleficence
Nonmaleficence is defined as “the duty to do no harm,” (Potter & Perry, 2010, p. 314). This principal is ingrained in the Code of Ethics for Nurses. It asserts that the nurse “must not knowingly act in a manner that would intentionally harm the patient,” (Marshall, 2001, p. 12). Some treatments have high risks of causing harm to the patient, but they also have great good for the patient, for instance, chemotherapy and bone marrow transplant which can make the patient weaker and vulnerable to opportunistic infections but which may cure the illness. The lack of nonmaleficence is evident in the movie “Wit” in various ways.
First and foremost, Vivian, the patient was diagnosed with ovarian cancer at the latest stage, that is, stage 4. This thus implies that it was almost impossible for her cancer to be cured. Nevertheless, the doctors at the hospital admitted her and began giving her doses of chemotherapy. To the doctors, Vivian was not just a patient but an object of research, a guinea pig on which the doctors could carry out their research studies and advance their knowledge and prestige in the medical field. The doctors knew that the doses of chemotherapy they were giving Vivian were not helping her in any way but were instead making her body weaker and weaker. Yet, they continued with the treatment and expected her to persevere it.
At the beginning of the play, Dr. Kelekian informed Vivian that they expected full cooperation from her when he stated that: ‘We will of course be relying on your resolve to withstand some of the more pernicious side effects,” (Edson, 2002, p. 9).
Moreover, Vivian had the option of receiving a lesser dose of the chemotherapy. However, the doctors insisted on the full dosage for the sole purpose of the research. Dr. Kelekian argued that: there may be times when you’ll wish for a lesser dose, due to the side effects. But we’ve got to go full-force. The experimental phase has got to have the maximum dose to be of any use,” (Edson, 2002, p. 11). A significant harm was inflicted on Vivian and included not only physical harm through weakening of her body, but also emotional and psychology harm.
Veracity
Veracity is defined as “telling the truth,” (Chitty & Black, 2007, p. 120). Telling the truth has usually been regarded as a basic necessity in human relations. Ingrained in the nurse-patient relationships is the assumption that nurses will be honest with their patients. However, in some cases nurses are limited by an organizational system that limits the nurse on what she can tell the patient. In such cases, the nurse engages in involuntary withholding of the truth. Voluntary deception is however considered to be immoral. Persons in need of healthcare may also not be totally honest when giving their health information.
Likewise, healthcare professionals may not be honest when responding to patients’ inquiries for information related to their treatment or prognosis. Reasons for such dishonesty include the notion that patients would be better off not knowing certain information or that they are not capable of understanding the information (Erichsen, Danielsson & Friedrichsen, 2010).
Veracity is evident in the movie “Wit” when Susan, the registered nurse taking care of Vivian decided to tell Vivian the truth about her condition. Vivian was getting large doses of cancer chemotherapy without any success of remission. In fact, the cancer was progressing at an alarming rate. She was near death, but the research physicians wanted to challenge her body with chemotherapy for as long as possible to observe the outcome.
Everyone on the medical staff had been cold, technically-minded, and no one had shown any concern for her except for Susie. Vivian had not been informed about the chemotherapy failure or the prognosis that she was dying. One night, Susan found Vivian crying and in a state of panic. She first helped to calm her, then shared a popsicle with her at the bedside while she disclosed the full truth to Vivian about her chemotherapy, her prognosis, her choices about her code status in case her heart stopped, that is, whether Code Blue or DNR, as well as her imminent death.
Susie affectionately explained: “You can be “full code” which means that if your heart stops, they’ll cal a Code Blue and the code team will come and resuscitate you and take you to Intensive Care until you stabilize again. Or you can be “Do Not Resuscitate,” so if your heart stops we’ll … well we’ll just let it. You’ll be “DNR.” You can think about it, but I wanted to present both choices …” (Edson, 2002, p. 67). Susie therefore felt an urge to be truthful an honest. By giving human respect to Vivian, Susie was showing her capacity to be human.
Fidelity
Fidelity refers to faithfulness or honoring one’s commitments or promises to patients (Chitty & Black, 2007). The nurse is supposed to be faithful to her role by seriously taking into consideration all ethical responsibilities related to the practice. When nurses accept patients, they are bound to offer the best care to them. Failure to do so is unethical. Commitment to promises, commitments and agreements builds the trust that is crucial for the nurse-patient relationship.
In the movie “Wit,” fidelity is illustrated well by Nurse Susan who goes out of her way to take care of Vivian and comfort her. She responds to her every need whether physical, emotional or psychological. She feeds her, keeps her company, talks with her, clams her when she is distressed and informs her of the progress of her condition. She also advocates for her healthcare by intervening when the doctors fail to take the proper action. Through all these, Susan shows her commitment to her profession. This creates a trustful relationship between her and Vivian (Dahlin, 2004).
On the other hand, the lack of fidelity is also illustrated in several occasions. First and foremost, any healthcare professional is bound by his practicing license to provide utmost care to their patients. By taking on Vivian as his patient, Dr. Kelekian was committed to provide the best care that would help alleviate her suffering and improve her quality of life if the illness would not be cured. This commitment was however not upheld.
This is because Dr. Kelekian and his fellow, Jason, were more interested in research that would increase their knowledge and enhance their medical careers. As a result, Vivian became a guinea pig for testing the effects of the new treatments. Although the treatments had adverse effects on her, the physicians did not stop or reduce the dosage in spite of the advice given to them by Nurse Susan. In the end, Vivian not only died from the cancer but the quality of her last days was deteriorated by the treatments.
Legal Issues Identified in the Movie
Malpractice
Malpractice is considered to be “the greatest legal concern of healthcare practitioners,” (Chitty & Black, 2007, p. 92). It refers to negligence applied to the acts of a professional. It occurs when a professional fails to act as a reasonably prudent professional would have acted under the circumstances. It is not a necessity to prove that a healthcare professional had the intention of being negligent. The legal action may be based on the wrong done either through commission or omission. The precondition of a malpractice action is based on two factors including the nurse’s specialized knowledge and skills and the patient’s harm inflicted by the nurse in the execution of her duties.
Malpractice is a key ethical issue raised in the movie “Wit.” Malpractice in the movie is reflected by the physicians’ refusal to act reasonably given the condition of Vivian. When Vivian was diagnosed with the ovarian cancer, the doctors knew that chances for her survival were minimal, if not non-existent. Despite this knowledge, they proceeded with the full dose treatment of chemotherapy thus inflicting great physical, emotional and psychological harm on Vivian.
For eight months, Vivian endured the painful treatment and its more painful and distressing side effects. To make the situation worse, the doctors did not provide Vivian with medications for the side effects until Susan the primary nurse intervened. All these constitute malpractice on the part of Dr. Kelekian and his fellow, Jason.
Informed Consent
This principle requires all patients to be granted the chance to give informed consent before any treatment except when there is a life-threatening emergency (Chitty & Black, 2007). The consent must be voluntary, must be given by an individual with the capacity and competence to understand, and based on adequate information. In the movie “Wit,” Dr. Kelekian gave Vivian the informed consent form to sign after briefly giving her the details about her condition and the treatments they would give her. However, the information given to Vivian about her condition and treatment was inadequate and full of medical jargons thus making it hard for Vivian to comprehend the full meaning of what the doctor said. Thus, the consent given was not an informed consent (Layman, 2009).
Impact of Legal/Ethical Issues on the Healthcare Delivered
The major impact the ethical and legal issues raised in the movie had on Vivian’s care was the deterioration of her health. The treatment given to her was too strong for her weakening body and as a result her health deteriorated with each cycle of treatment she received. In addition, illegal and unethical practices deteriorate the quality of life of patients. In Vivian’s case, the treatment she received prolonged her life but her life was full of misery and agonizing pain.
In the end, the agonizing treatment did not cure her illness and instead she died. If Vivian had had the opportunity to make informed consent to the treatments she received and if the physicians had been honest with her from the beginning, she would not have suffered the way she did. Second, the lack of humanity on the part of the doctors when dealing with Vivian had negative effects on her emotional health. Vivian cried out of frustration and distress on many occasions. She felt helpless and as an object to be used, abused and poked at the discretion of her physicians. This is illustrated when she laments that: “I receive chemotherapy, throw up, am subjected to countless indignities, feel better, go home,” (Edson, 2002, p. 41).
Factors that Contributed to the Lapses in the Standards of Care
In this particular movie, the standards of care were not upheld because of a number of factors. The first factor is the interest of the medical professionals. Dr. Kelekian and his fellow Jason were carrying out a research study that would help them come up with a more effective treatment for ovarian cancer. However, the treatment they were working on needed experimentation. When Vivian came to the hospital with stage 4 ovarian cancer, the doctors saw it as a good opportunity to carry out the experimentation. Vivian was put through the full dose of chemotherapy irrespective of the negative consequences it had on her. As a result, standards of care were compromised for the sake of advancing knowledge (Ulrich Zhou & Grady, 2009).
The second factor that contributed to the compromise of standards of care at the organization is the organizational climate. An organizational climate that upholds standards of care should be created by the managers or senior professionals of the organization. In Vivian’s case, the senior medical professionals (Dr. Kelekian and his fellow, Jason) were at the forefront in compromising standards of care. Although the nurse could identify the unethical and illegal practices, she lacked the power to bring them to an end. The only thing she could was to advocate for better care for Vivian but the ultimate decision lay with Dr. Kelekian. Commitment from the management and senior professionals is thus important in upholding standards of care.
Strategies and Resources that could be used in Coping with the Identified Issues Immediate Strategies
Any healthcare organization interested in ending unethical practices in the short-term can undertake several strategies. The first strategy requires nurses to recognize situations in which healthcare professionals such as physicians compromise the ethical values or situations in which the ethical values conflict. Nurses may experience a troublesome sense in cases when something does not feel right, thus showing that certain duty or task may not have been carried out in the best or most appropriate manner (Kelly, 1998). Nurses need to admit to such feelings not only to themselves but also to their peers and should thus start discussions about the situations, which will in turn help in validating the encounters and clarifying feelings of uncertainty or distress.
Once nurses recognize moral distress or an ethical dilemma and become motivated to take action, they can undertake a six-step process described by Purtillo (2005) to analyze and resolve ethical problems in clinical situations. Ideally, nurses will not be working in isolation to resolve dilemmas but will be engaged in collaborative inquiry and dialogue with other members of the healthcare team. The familiar problem-solving process involves the steps of assessing, identifying the ethical problem, analyzing the problem, exploring the options, implementing the action, and evaluating the process outcome (Cohen & Erickson, 2007).
Long-term Strategies
In the long-term, healthcare organizations should set up ethics committees and ethics consultation services to provide assistance to staff, patients, and families. The multidisciplinary committees can provide unique views to every situation that includes ethical questions. Senior clinicians who serve on the committees are excellent resources for new and seasoned nurses. Ethics consultation services include individuals with expertise in bioethics and clinical decision making who help facilitate communication, mediate conflicts, and alleviate distress in nurse caregivers (Clark & Taxis, 2003).
Ethics rounds and nursing ethics committees also are avenues for healthcare providers to discuss morally distressing situations and to identify strategies for coping. During ethics rounds, nurses and other members of the healthcare team have an opportunity to focus on specific cases with ethical dilemmas that cross all disciplines (American Nurses Association, 2001).
Nursing ethics groups, composed only of nurses, also can be formed to develop nursing competencies and skills necessary for ethical problem solving (Andrews, 2004). In such a forum, nurses can discuss difficult cases and identify issues that may require policy changes. Such groups also can provide opportunities for nurses to learn, apply, and practice the process behind analyzing and solving ethical dilemmas. Many schools of nursing have clinical faculty who specialize in nursing ethics and who are excellent resources for consultation. Clinicians also can seek individual guidance from ethicists in their organizations or communities who are skilled and knowledgeable in ethical theory (Hamric, 2002).
Nurses are encouraged to complete formal education in ethics through electives or continuing education courses. Courses are available through schools of nursing, healthcare institutions, and professional organizations.
Distance-learning classes may be offered to accommodate broad audiences (Ellenchild-Pinch & Graves, 2000; Jameton, 1993). Journal clubs or brown bag lunch discussions are opportunities for staff to develop the communication and critical-thinking skills needed for ethical analysis (Turner, 2003). Educational offerings may focus on the role of nurses in supporting ethical practice, increasing awareness of the impact of ethical dilemmas in the healthcare setting, and enhancing nurses’ abilities to form ethical arguments and justify decisions (Matzo, Sherman, Nelson-Marten, Rhome, & Grant, 2004).
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