Healthcare professionals face the challenge of resolving ethical dilemmas on a regular basis. This paper will discuss a hypothetical ethical dilemma in a healthcare setting as if it were the author’s. Competing loyalties between the organization and patient will be indentified and an ethical response will be provided along with contrasting ethical responses. Implications to risk management will be considered and an ethical decision making model will be identified to guide future actions. The Situation
Clumsy Walker is an 82 year old female that has been hospitalized due to pneumonia. She has mild dementia and is a high fall risk. She has a history of broken hips and has a tendency to wonder and has been found wondering the halls twice by staff members on two separate occasions. Mrs. Walker has an intravenous (IV) line. The staff has expressed concern that she may fall and dislodge the IV or wander off somewhere and unintentionally hurt herself. As a result, the suggestion has been made to restrain Mrs. Walker although she has been adamant that she does not want to be restrained. The Ethical Dilemma
An ethical dilemma is “a situation that requires an individual to make a choice between two equally unfavorable alternatives” (Aiken, 2004, p.100). In this case, the ethical dilemma is whether to restrain Mrs. Walker against her will and thus protect herself and the organization or to respect her wish to not be restrained and determine an acceptable alternative course of action.
Competing Loyalties The healthcare provider has competing loyalties between the organization and the patient. One of the healthcare provider’s primary loyalties is a duty to do good for the patient (beneficence) and in this case doing no harm (non-maleficence) (Aiken, 2004). They also have a duty to the organization to minimize liability by managing the fall risk, or other potential harm to the patient. “Unfortunately, in situations where patients are unable to make decisions for themselves, the resolution of the dilemma often appears to be a unilateral decision made about the individual’s health care by the health care providers. This type of unilateral decision by health care providers, disregarding the patient’s wishes and implying that the health care provider knows best, is paternalistic” (Aiken, 2004, p.111). Ethical Response
Mrs. Walker’s mild dementia inhibits her ability to remain consistently lucid. Thus it is believed that no matter how much care is taken to explain to her the harm she could experience if she attempts to walk unassisted, there is no guarantee that she will remember these instructions. The only living family member is her daughter who lives out of state and she is not able to come to the hospital to sit by her mother during this time. Her daughter also stated that she was in opposition to having her mother restrained. It is the opinion of the attending physician that she not be allowed to become ambulatory without assistance.
After gathering as much information as possible and consulting with as many interested parties as appropriate, a decision was made. In Mrs. Walker’s case, the most ethical response was determined to be the use a modified bed with extra high rails. This essentially placed her in a protective environment that made it virtually impossible for Mrs. Walker to get out of bed without assistance. Additionally the nurse call button was repositioned so that Mrs. Walker could have easier access to it. Staff was scheduled to check in on her every half hour. A sign was also placed on the wall in a conspicuous location that stated, ‘For assistance in getting out of bed, please ring the nurse call button’. In other words, Mrs. Walker was constrained without being restrained. Consequently, the interests of the hospital were protected and the requests of the patient were respected. Alternative Ethical Response
The very nature of ethical dilemmas is that no matter how they are resolved there will likely be dissention and second guessing after the fact. This situation was no different. The minority opinion was to transfer Mrs. Walker to another facility that was better able to accommodate Mrs. Walker’s needs. This would have been a valid alternative had Mrs. Walker’s insurance covered such a facility. Implications to Risk Management
In a healthcare setting, almost all decisions should be considered within the context of risk management. In our hypothetical scenario, the proposal to restrain Mrs. Walker had been made in order to protect her from harm and to protect the hospital from liability. However, had they restrained Mrs. Walker against her will and her daughter’s wishes, it could have also opened the door for a lawsuit. The ethical response described in this paper provided an alternative that respected all parties’ interests and minimized risk exposure for the healthcare organization. Possible Ethical Decision Making Model
There are several different ethical decision making models in use today. The following five-step ethical decision-making process is outlined by Aiken as a tool for resolving ethical dilemmas.
Step 1: Collect, Analyze, and Interpret the Data
Obtain as much information as possible about the particular ethical dilemma to be decided. After collecting information, bring the pieces of information together in a manner that gives the clearest and sharpest focus to the dilemma.
Step 2: State the Dilemma
State the dilemma as clearly as possible. Most of the time, the dilemma can be reduced to a statement or two that revolves around the key ethical issues. These ethical issues often involve a question of conflicting rights or basic ethical principles.
Step 3: Consider the Choices of Action
List all the possible courses of action that can resolve the dilemma without considering the consequences. This undertaking needs to be a real brainstorming activity in which all possible courses of action are considered. Step 4: Analyze the Advantages and Disadvantages of Each Course of Action Consider the advantages and the disadvantages of each action, along with the consequences of taking each course of action. By considering the advantages and disadvantages, the healthcare professional should be able to pare the options down to the few realistic choices of action.
Step 5: Make the Decision
The best decision is one that is based on a sound ethical decision-making process. In resolving any ethical dilemma, questions will always remain regarding the correct course of action. (Aiken, 2004, p.104)
There is a constant competing loyalty for healthcare professionals between the organization they work for and the patients they serve. As a result, challenging ethical dilemmas in a healthcare setting are commonplace. Following ethical decision making models help healthcare professionals to pursue a framework for solving these dilemmas that not only results in defensible ethical outcomes but also helps to minimize risk management concerns for the organization.