Foundational Principles of Bioethics
Four principles are implemented to optimize and maximize patient outcomes: autonomy, non-maleficence, beneficence, and justice. The two principles that can generate conflict are autonomy and beneficence. On the one hand, healthcare providers are focused on well-being and health, which implies that measures must be implemented to achieve these results. On the other hand, patient-centered care is a pillar in nursing, and the decisions and preferences of individuals are to be considered at all times during treatment. The current paper presents an ethical dilemma in end-of-life care and argues that autonomy is paramount, grounded in the patient’s choices and desires.
Ethical Dilemma (Autonomy vs. Beneficence)
The case study illustrates the care of a 78-year-old patient receiving end-of-life care. Due to concerns for pain management, the doctor has prescribed opioids that are to be administered by the nurse. The patient reports cognition problems, nausea, and feeling sedated. Family members notice the changes, yet would like their grandfather not to be in pain and continue with the medicated treatment.
The patient expresses wanting to be fully lucid as he is aware that his condition will worsen, and time with family is limited. Hence, he does not want to proceed with the treatment administered by the nurse. Patients often prioritize cognition over pain management in end-of-life care scenarios (Wegier et al., 2020). However, the situation imposes an ethical dilemma on the nurse: continuing the treatment as it is beneficial for the patient’s well-being or respecting his autonomy to choose and stop the medications.
Importance to Nursing
The aforementioned case study underscores the importance of addressing ethical dilemmas in nursing. Researchers illustrate that autonomy and beneficence are two fundamental moral principles in bioethics (Cohen, 2019). However, there are circumstances in which one is more vital than the other. Needless to say, the ‘one size fits all’ approach is inadequate, considering that each patient has an individual story, experience, and goal (Scharf et al., 2021). Simultaneously, the importance of ethics lies in providing a basis for future decisions.
Relevant literature also emphasizes the delicate correlation between the principles of autonomy and beneficence (Amer, 2019). A patient’s wishes can correspond to the best solution for their well-being. However, in this case, there would not be a dilemma. However, the importance of considering situations in which the two are incompatible stems from the need to determine the best solution for each particular situation.
Another element that underscores the importance of resolving ethical dilemmas in nursing is the need to prioritize certain principles and clearly define them. An example is the concept of autonomy, which cannot always be defined as a patient’s right to choose their treatment (Akdeniz et al., 2021). In some cases, individuals may lack the capacity to make thoughtful, insightful decisions due to cognitive limitations. In other cases, the patient’s beneficence does not align with their wishes, as illustrated in the present case study. Hence, it is essential to consider such situations to determine the primacy of one principle over the other, even though all of them play a key role in healthcare and patient well-being.
Viewpoint
Patient autonomy is, arguably, the principle that is to be considered when deciding to stop the opioid administration to the patient in the case study. Universally, one principle cannot be considered more important than the other. Nonetheless, the fact that patient-centered care provides individuals with choices about their treatments underscores the importance of respecting those choices. Considering that autonomy directly correlates with truth-telling, the patient is informed of how confident choices will impact their lifespan and quality of life (Akdeniz et al., 2021). As per the patient in the case study, his goal is not pain minimization but maintaining cognition for as long as possible and not experiencing side effects from end-of-life care pain medication.
As the patient’s mental capacity is not impaired and he is aware of his condition, symptoms, and ways to manage them, the situation implies that autonomy should guide nursing. Beneficence cannot be fully implemented in this case because the patient’s interests do not align with the best health outcomes (Varkey, 2020). If beneficence were the only guiding principle, healthcare providers would sometimes have to contradict patients’ preferences to improve their quality of life and maximize longevity and health.
However, even though the value is highly applicable in most cases, ethical dilemmas present events in which what is best for the individual from a medical perspective does not coincide with their personal choices. Hence, the right decision would be to allow the patient to have control over the treatment. The nurse is to stop administering the opioids, regardless of pain management being vital for the individual’s condition.
Opposing Viewpoint
The opposing viewpoint would be prioritizing beneficence over the patient’s autonomy. In this case, the nurse would keep administering the pain medication as pain management is an essential principle in end-of-life care. This would improve the individual’s quality of life.
A variety of researchers mention the importance of implementing beneficence as a crucial value in treatment. It improves health outcomes and patient satisfaction and reduces mortality (Cheraghi et al., 2023). The notion itself implies that nurses have a moral obligation to act in the patient’s best interests regarding their health (Bifarin & Stonehouse, 2022). Needless to say, administering pain medication would result in a more comfortable, painless, and satisfactory experience for the patient. This is especially important in the context of end-of-life treatments, where one of the central premises is improving the quality of life.
Simultaneously, the concept of beneficence has been linked to nurse satisfaction. According to researchers, helping others is linked to personal satisfaction (Martela & Riekki, 2018). Hence, avoiding patient distress, which is undoubtedly linked to the minimization of prescription opioids when pain is a factor, would have positive effects both on the care provider and the patients themselves.
Professional Position
From a professional standpoint, the patient’s autonomy is essential, and their choices ultimately determine the care they receive. As previously highlighted, ethical principles cannot be ranked by importance, as they all play a crucial role in nursing (Rosenberg, 2021). Beneficence, as a concept, implies promoting the path that is most likely to correlate with patient well-being.
Hence, the appropriate professional position, based on the case study, involves informing the patient about the condition, treatment, and the expected outcomes of the medication, as well as what would happen if treatment is not followed correctly. In this case, health promotion is achieved through informational awareness. Additionally, the patient’s loved ones are to be informed of the circumstances (Scharf et al., 2021). However, autonomy prevails when considering the individual’s wishes.
Defense of Position
The position correlates with the concept of patient-centered care. This is supported by the relevant literature, which emphasizes that palliative care should be provided in accordance with each individual’s values and principles (Mapes et al., 2019). Similarly, care providers are to ensure that no harm is inflicted. In cases where the patient perceives pain management as harmful, nurses can fulfill their duties by ensuring lucidity in accordance with the individual’s wishes and preferences.
Another defense of the position is the legal context, which also correlates with the principle of autonomy (Reis-Dennis, 2020). From a legislative standpoint, patients should not be forced to take medications or participate in treatments they disapprove of.
Resolution
From an ethical and professional perspective, the most efficient decision is to fulfill the patient’s wishes and stop the pain management involving opioids. The resolution correlates with patient-centered care (Mapes et al., 2019). Although ethical principles cannot be ranked by importance, each situation highlights the element considered central.
In cases where the patient is aware of their condition and the treatment’s side effects are deemed adverse, the medications are to be changed or avoided as per the individual’s wishes. The case study presents a situation in which the individual receiving end-of-life care is not cognitively impaired and can make confident decisions regarding his care. Hence, nurses are to respect such desires and accept that, despite the moral dilemma, the preferences of the care recipient are critical.
References
Akdeniz, M., Yardımcı, B., & Kavukcu, E. (2021). Ethical considerations at the end-of-life care. SAGE Open Medicine, 9, 205031212110009.
Amer, A. B. (2019). The ethics of veracity and it is importance in the medical ethics. Open Journal of Nursing, 09(02), 194–198.
Bifarin, O., & Stonehouse, D. (2022). Beneficence and non-maleficence: Collaborative practice and Harm Mitigation. British Journal of Healthcare Assistants, 16(2), 70–74.
Cheraghi, R., Valizadeh, L., Zamanzadeh, V., Hassankhani, H., & Jafarzadeh, A. (2023). Clarification of ethical principle of the beneficence in nursing care: An integrative review. BMC Nursing, 22(1).
Cohen, S. (2019). The logic of the interaction between beneficence and respect for autonomy. Medicine, Health Care and Philosophy, 22(2), 297–304.
Mapes, M. V., DePergola, P. A., & McGee, W. T. (2019a). Patient-centered care and autonomy: Shared decision-making in practice and a suggestion for practical application in the critically ill. Journal of Intensive Care Medicine, 35(11), 1352–1355.
Martela, F., & Riekki, T. J. (2018). Autonomy, competence, relatedness, and beneficence: A multicultural comparison of the four pathways to meaningful work. Frontiers in Psychology, 9.
Reis-Dennis, S. (2020). Understanding autonomy: An urgent intervention. Journal of Law and the Biosciences, 7(1).
Rosenberg, S. (2021). Why ethics in nursing matters. Southern New Hampshire University.
Scharf, A., Voigt, L., Vardhana, S., Matsoukas, K., Wall, L. M., Arevalo, M., & Diamond, L. C. (2021). What should clinicians do when a patient’s autonomy undermines her being treated equitably? AMA Journal of Ethics, 23(2).
Varkey, B. (2020). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28.
Wegier, P., Varenbut, J., Bernstein, M., Lawlor, P. G., & Isenberg, S. R. (2020). “No thanks, I don’t want to see snakes again“: A qualitative study of pain management versus preservation of cognition in Palliative Care Patients. BMC Palliative Care, 19(1).