Ethical Legal Dilemmas in Nursing

Ethical Legal Dilemmas in Nursing

The profession of advanced practice nursing is characterized by several attributes, one of them being the delicate balance between the law and the ethical code. One may argue that the legal system was designed around ethical principles but in the following paper, the author will attempt to point out the distinctions that separate and define legal and ethical reasoning. A thorough discussion regarding legal interpretation, coherence and logic will be supported by case law as well as analysis. In contrast, the function, problem and logic of ethical reasoning will be outlined along with the elements, advantages, and disadvantages of this interpretive and highly personal moral code. As a nurse, recognizing the traits that define ethics and law will offer one the best chance of making decisions that will uphold the ethical code of nursing while reflecting the laws put forth to govern its existence. Case Study

A 40 year old male patient with delusions of parasitosis (DP) is seen in the dermatology clinic for follow-up. The patient has had several biopsies and laboratory tests and none have shown any evidence of parasitic infestation or other primary disease processes. The patient has gone through periods where the symptoms were better and sometimes that have worsened but at this time he seems to be experiencing a flare. The patient, in desperation, asks if the NP can perform another biopsy or if he can use stronger medications so he can be cured. Upon examination, the Nurse Practitioner (NP) notes multiple superficial erosions, most likely excoriations, of his upper and lower extremities. In addition, there are some overlying crusts and erythema suggestive of a secondary infection. On the previous visit, the NP suggested a psychiatric consultation to the patient who refused stating that he did not understand why he should see a psychiatrist for a skin condition.

DP presents itself as a result of the patient reacting to delusional cutaneous manifestations by scratching and picking at their skin (Wong and
Koo, 2013). Although a few dermatologists have suggested that there may be an underlying primary disease process, the majority of dermatologists support the idea that DP is a psychiatric condition and should be treated as such. The Centers for Disease Control and Prevention (CDC) have undertaken steps to study DP and its dermatopathology in hopes of gaining insight into factors that may contribute to the illness. Legal Dilemmas

By complying with the patients’ request for another cutaneous skin biopsy, the NP could be accused of health care fraud. Agreeing to perform the biopsy without any new evidence that would support another biopsy, the payer could perceive an intent to deceive. An activity is considered fraudulent when the person knowingly engages in the act for the purpose of achieving some monetary gain (Theoharris, 2013). Fraud can be prosecuted at both the civil and criminal levels and fines and/or sanctions can be levied against the offenders (Bradley, Monarch and Bhimji, 2013). Furthermore, the medical necessity of the biopsy could be challenged and deemed an act of abuse. Fraud and abuse generally go hand in hand and, as a result, the repercussions are the same. Legal Reasoning Constructs

In the attempt to understand the law, one must understand that the legal perspective is characterized by how one thinks about law and its effects. Legal theorists divide legal reasoning into two distinct areas pertaining to the definition of law and how cases should be decided by examining the content of the law in respect to how previous cases were decided (Comock, 2011).

Interpretation in Legal Reasoning
In examining the issue of the NP attempting to treat a patient with parasitosis, one must consider the legal implications of their actions as well as the consequences. The possibilities of treatment modalities are considered in terms of how the patient will react, thus, placing this situation into the area of consequential rules. As dermatologists are “allowed” to prescribe antipsychotic medications if they are “comfortable,” then regulatory law does not really apply in this situation. Previous cases have determined that there are several viable treatment possibilities,
leaving the physician open to choosing the treatment that best suits the particular patient and their circumstances. Coherence in Legal Reasoning

The consistency of legal reasoning can be attributed to its ability to explain how decisions are made (Dickson, 2010). The decision by the NP to partake in a multidisciplinary approach to treatment abides by the underlying issues at hand. The patient is viewed as unstable and in need of psychiatric care as well as primary medical care for an apparent infection. These two diagnoses are considered during the treatment planning stage. Logic in Legal Reasoning

By examining the relevant factors in a case, the NP must consider that the fiduciary gain of performing an unnecessary biopsy would support illogical reasoning in this case. An activity is considered fraudulent when the person knowingly engages in the act for the purpose of achieving some monetary gain (Theoharris, 2013). In addition, the ethical consequences of such an act undermine the principle of nonmaleficence because the biopsy would essentially harm the patient by causing him undue pain (Schatzberg & Nemeroff, 2009).

Case Law
The term ‘case law’ applies to the decisions and interpretations made by judges while deciding on legal issues (LAWS, 2013). As a significant number of patients seen by dermatologists have skin disease complicated by a psychiatric condition, dermatologists must be familiar with antipsychotic medications (Ghosh, Behere, Sharma & Sreejayan, 2013). Traditional dermatology does not usually emphasize psychiatric management, but cases such as this one can support such methodology. The application of ethical-legal standards can be supported by published literature. Legal Analysis

As an advanced practice nurse, the concept of legal analysis must be understood within the context of medical decision making. One must be familiar with the legal implications of one’s actions and be able to examine the facts in order to make a supported decision (Klaassen, Smith & Witt, 2011). As the NP understands the role of the medical professional in the
diagnosis and treatment of a multifaceted condition, the analysis must reflect current knowledge regarding treatment parameters and accepted protocol. In addition, feasibility and establishment of goals must be clearly defined in order to defend treatment activities. Ethical Dilemmas

It can be difficult for practitioners to treat delusional patients with DP as the patient may not have the capacity to understand their condition. By prescribing an anti-parasitic as requested by the patient, the ethical principle of beneficence may be violated as the medication would not be of any benefit to him. In addition, by not fully explaining the disease process to the patient, perhaps to avoid upsetting the patient, the NP is not providing full disclosure which could then be construed as a violation of the patients’ autonomy. Finally, the NP could be in violation of the ethical principle of veracity as to prescribe the anti-parasitic medication in the absence of a parasitic disease would be misleading and/or deceitful. Ethical Reasoning

According to the Association of American Colleges and Universities (2013), the analysis of human conduct is defined as “ethical reasoning.” Insight into the basic principles surrounding ethical reasoning is gained by the examination of its function and logic. Essential elements vital to the reasoning process must also be clearly defined so as to prevent corruption of the reasoning process. For the healthcare industry, the importance of ethical reasoning lies in the fact that decisions made by a caregiver will affects the welfare of another and ultimately guide their understanding of moral responsibility. The principles of ethics are demonstrated not by one’s words but by their actions (Elder & Paul, 2011). Function of Ethical Reasoning

In examining the function of ethical reasoning, one could ascertain that by examining the rationale behind potential ethical decisions, one may begin to place their own moral values within the context of the situation. By doing this, a scenario is created in which to place the ethical dilemma. The creation of the scenario allows the decision-maker to analyze their choices and appreciate the related consequences. By disallowing other extraneous
variables, one can focus on the basic ethical principles at hand and weigh the possibilities without bias. In this process lies the basic function of ethical reasoning. The NP must defer to the ethical principle governing nursing practice when considering options for treatment. Weighing medical benefits against potential harms should guide the NP in the decision-making process.

The Problem of Pseudo-Ethics
The intermingling of ethics with other modes of thought can lead to decisions influenced by such things as religion and law. As there are many forms of religion, the principles guiding each one of them may differ. The select beliefs of a religious group are usually based on spirituality which is not based on ethical principles. In legal circles, laws are formed to deem certain acts illegal. An acts legality is not determined by the principles governing ethics. Allowing religion and law to confuse the ethical thought process may lead to a decision based not on ethical principle but on personal beliefs and conveyance. An example of a decision tainted with pseudo ethical ideals would be the NP not considering antipsychotic medication as their religious beliefs prohibit their use. Elements of Ethical Reasoning

Ethical reasoning involves the NP defining the issue and their purpose within the issue. In this case, the issue is how best to proceed with the patient with parasitosis. The recognition of assumptions and the collection of data to prove or disprove those assumption must be undertaken prior to any treatment decision. The NP must be able to take into account the patients’ feelings and perceptions so as not to upset the therapeutic relationship while clarifying the concepts involved in the reasoning process (Valentine & Bateman, 2011). Before deciding on a treatment, the NP must decide if the reasoning is supported by the information and consider any consequences of their actions. Logic of Ethical Reasoning

As one of the main functions of nursing is to provide care, ethical reasoning supports our actions and defines the profession as a whole. In order to make any decision related to the patients’ well-being, the logical
process of weighing ethical challenges and outcomes must occur. In the case of the patient with parasitosis, the NP must maintain an ethical standard of beneficence while upholding nonmaleficence and justice. As this case involves a delusional patient, the possibility of impaired autonomy must be factored into the reasoning process. For this reason, the NP can justify treating the psychosis first in order to strengthen the patients’ autonomy. Advantages and Disadvantages of Ethical Reasoning

The advantages of ethical reasoning far outweigh any disadvantages as ethical reasoning is based on principalities stemming from moral conduct and responsibility (Bradley, Monarch, & Bhimji, 2013). Emphasis on beneficence exemplifies the role ethics plays in the NP’s decision making process and further supports the actions undertaken. Rationality is further exemplified by the ethical reasoning process but some argue that the process “clouds” the issues by overshadowing and eliciting a subjective stance. By providing only two choices, right and wrong, the NP may overlook viable options such as combination therapy for the patient. A Treatment Decision

In a scenario such as the one presented, it is imperative for the NP to consider the treatment options available given the apparent representation of multiple disciplines. For the psychiatric patient, the establishment of a trusting relationship between the patient and provider is paramount in any treatment regimen. The narrative method is comprised of interacting with a patient in order to glean insight into their life (Wallis, Burns and Capdevila, 2010). By being supportive and communicating in a non-confrontational manner, the clinician can ascertain useful information which will assist him or her in making the appropriate decisions for treatment.

The standard medical evaluation or interview can gather essential information to facilitate the narrative approach. By gaining a more in-depth understanding of the patient as a whole being, the NP can view the patients’ symptoms from their perspective which will allow them to gain deeper insight into how the patient may feel about discussing their issues with another practitioner, possibly a psychiatrist. Most important in the
narrative approach is for the NP to acknowledge the patients’ suffering and discuss the patients’ feelings about various treatments (Sandoz, LoPiccolo, Kunsit and Tausk, 2008). In the end, the patient may be more receptive to a multidisciplinary treatment approach including dermatologists, psychiatrists, and counselors. Conclusion

As demonstrated by this outline of ethical and legal issues, the decision-making process can be extremely complex and involved. Taking into consideration the legality of a decision as well as the ethical principle can present a challenge for the advanced practice nurse in any setting. The advanced practice nurse must demonstrate ethical thinking and be familiar with legal challenges so that their decisions reflect the humanity of healthcare and its implications for future practice. Critical thinking in situations that challenge our ethical and legal obligations allow the process of reasoning to occur which leads to well-informed decisions.

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