CONSENT MUST BE GIVEN BY AN APPROPRIATELY INFORMED PERSON
The literature suggests that patients have little or no understanding of the procedures or the risks that they consent to (Taplin 1995, Kennet 1986) The patient had previously undergone extensive treatment for his malignancy and may have equated the scan with a previous traumatic experience of treatment. It is reasonable to expect, as Ley 1982 (cited in McParland et al 2000 p662) discussed, that such experiences could cause anxiety and apprehension resulting in a lack of understanding or forgetfulness. The ruling from the case of Sidaway v Bethlem Royal Hospital Governers (1985) showed that the duty of care includes the duty to inform. However, as the case of Chatterton v Gerson (1981) determined, the patient only needs to understand in broad terms the nature of the procedure. A further point to consider is the dilemma encountered when a patient may not appear to want information about a procedure. Information given in accordance with the principles laid down by Bolam v Friern Hospital Management Committee (1957) ensures a duty to inform is fulfilled. Furthermore, recognition of the nurses’ legal duty to inform, is found in clause 2 of the Code of Conduct UKCC (1992). Professional accountability requires nurses to ensure that a duty of care is of a reasonable standard. The law also makes provision for treating a patient without his agreement if his medical condition temporarily inhibits his ability to take in information. For example, in the case of Re F (1990), the House of Lords ruled that treatment could be given as long as it was in the best interests of the patient
CAPACITY
Currently, according to Wong et al (1999), there is no universal standard for determining capacity. However, in the case of Re C (1994), Thorpe J. suggested a three part test to determine the capacity of a patient. In practice, as Grubb 1994 (cited in McHale et al 1998 p63) reports the test makes capacity dependant upon the information given to the patient. For example, a complex explanation may not be readily understood whereas the same explanation delivered in a more basic manner may be followed more easily. The unthinking or routine practice of healthcare professionals may lead to patients feeling undignified or losing their self-respect. For example, Pellegrino 1982 (cited in Woodward 1998 p1049) emphasises the importance of having regard for the patient’s values.
In addition, although the case of Gillick v West Norfolk & Wisbech Area Health Authority (1986) ruled that age or diagnosis should not determine validity, integral to caring for older people in any setting or circumstance is an understanding of adjustment and ageing in later life. Older people can feel particularly vulnerable in hospital for many reasons. It could be that the nature of the patient’s disease has engendered feelings of hopelessness about his future or that he feels too ill to be care about making decisions. As Bird (1994) discusses illness can cause patient’s uncertainty and they frequently change their minds about what course of action to follow. If this is the case, it may be inappropriate to expect the patient to take an active role in their decision-making. Furthermore, from Redfern’s (1996) discourse, it is apparent that despite the current emphasis on patient involvement and autonomy, patients sometimes wish to adopt a more passive and dependent role.
ETHICAL THEORIES
Sparks 1991 (cited in Kendrick 1994 p2) defines ethics as a philosophical study of moral conduct and reasoning.
Within the healthcare context, Utilitarian ethics (Bentham 1748-1832 and Mill 1806-1873) and Deontological ethics Kant (1724-1873) are the theories most commonly employed to resolve moral dilemmas. The two ethical theories of Utilitarianism and Deontology take opposing views about the rightness or wrongness of acts or decisions. From a utilitarian perspective, the focus is on the consequences of decisions and actions. The morally correct act being the one that results in the greatest benefit and the least harm. For example, It may be that the consequences of not having a CT scan would hinder future beneficial management of the patient’s condition. On the other hand, the patient is considered to have the capacity to make decisions and going against his wishes could result in loss of self-esteem and well-being.
Alternatively, the deontological view relies on rules that make no reference to consequences but consider duty to be the basis of morality. The fundamental essence of the theory being “one must act to treat every person as an end and never as a means only”. Duty based ethics compare well with the ideology of nursing. For instance, the clauses of the Code of Professional Conduct UKCC (1992) give guidance to the professional duties of the nurse. However, in practice, there can be conflicting obligations to duty. For example, in the scenario, the duty to act in accordance with the patient’s wishes may conflict with the duty to prevent harm. Although, acting out of respect for duty appears to carry plausibility within nursing. It would appear that at some point a compromise would need to be considered.
As Goodhall (1997) argues, adhering to one or other of the main ethical theories could have shortcomings, as neither are totally appropriate or workable within the health care setting.
Using a framework such as the Biomedical Model identified by Beauchamp & Childress (1994) provides a structure for moral reasoning. Edwards (1996) contends that it is the level three principles of the framework that are most relevant to moral deliberation in nursing ethics. From my previous experience, the close relationship between level three principles and the clauses of the Code of Conduct UKCC (1992) support ethical decision-making in nursing. However, obligations generated by level three principles can result in ethical dilemmas. The issues in the scenario will be discussed within the framework of the level three principles pertinent to the situation.
RESPECT FOR PATIENT AUTONOMY
The concept of patient autonomy has become increasingly popular in nursing. For instance, from a government perspective, The NHS Plan Department of Health (2000) and the National Service Frameworks for Older People Department of Health (2001) strongly suggests that patient’s have the right to be given clear explanations of proposed treatments before choosing whether or not they wish to be treated. From the nursing perspective, Clause 5 of the Code of Conduct UKCC (1992) emphasises that it is the nurses’ responsibility to recognise and respect the involvement of patients in care delivery. The overall expectation of these notions being the patients control of their situation. Edwards (1996) defines autonomy as the ability to decide and act on the basis of reason. Given this fact, it may be considered that the nurse has a responsibility to ensure the patient receives the appropriate information to make a reasoned decision and that he has the capacity to do so. Therefore, within the scope of the scenario, it would appear right to support the patient’s decision not to have a CT scan as long as the patient’s capacity was assured and he had received enough information to weigh up the consequences of his action.
PRINCIPLE OF BENEFICENCE
According to Beauchamp and Childress (1994) beneficence is concerned with promoting good and preventing harm. From a nursing perspective, the responsibility for the patient’s well-being and avoiding actions that are detrimental to them is laid down within Clauses 1 & 2 of the Code of Conduct UKCC (1992). Taking into account the situation in the scenario, it could be argued that, undergoing a CT scan would be beneficial to the patients’ future management. Reeder 1982 (cited in Willard 1996 p63) suggests that beneficence includes helping those who require assistance. For instance, as Bird (1994) discusses illness and anxiety can cause uncertainty and it may be inappropriate to expect them to take an active role in decision-making. Older people, in particular, see doctors as people with expert knowledge and trust them to know the best course of action. Gillon (1995) presents the alternative view that people’s perception of harm is an integral part of how they see themselves and their life plan. Therefore, it is important when talking of preventing harm to consider the patient’s perspective as well as our own duty. This can be justified from the utilitarian stance on the grounds of maximising the patient’s well-being and from the deontological point of view that respect for persons and their autonomy is a fundamental law. The patient’s concept of harm may have been to continue to suffer in the short time that he had left to live and the greatest benefit would be in not prolonging the inevitable. The euthanasia debate is not within the remit of this essay but the relevance to the situation is acknowledged.
SUMMARY
As we have seen, the critical factor in ensuring consent is valid is the capacity of the patient to make an autonomous decision. Legally and ethically the patient’s original refusal of the CT scan and his subsequent change of mind is clearly valid. However, nurses have a duty and a responsibility to ensure that the patient has the relevant information to make a reasoned decision in accordance with his own values. Morally, the focus must remain on the patient ensuring any actions that we take are with good intent and according to the patient’s values. Even if we are not in agreement with the patient’s decision we remain legally and professionally accountable for continuing to provide the best possible care.
The patient underwent the CT scan, which showed further infiltration of his tumour causing an intestinal obstruction. Further treatment was palliative to control pain and reduce any distress. He died peacefully four days later.
CONCLUSION
The overall theme of this essay concerns determination of the validity of consent. The focus has been on issues arising from a particular patient scenario. These issues centred on the patient’s refusal of treatment and subsequent change of mind. The dilemma highlighted the crucial role that both law and ethics have in day to day nursing care. From my point of view, it has shown that in practice there can be confusion around the meaning of consent and it’s relationship to nursing. Finally, there is scope within my present role to discuss these issues further with Trust nurses.
