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Ethical Dilemmas

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"Karen" is a new nurse practitioner who has just started her first NP position in a family practice clinic in a small town. She sees "Susan Ruttley," a 29-year-old primigravida woman who is newly pregnant (5 weeks since last menstrual period) and wants to initiate prenatal care. Susan is married but presents alone, stating that her husband is not yet aware of the pregnancy. She desires a child but is not ready to tell him of the pregnancy because he has been insisting that they delay parenthood due to financial difficulties. The NP recommends HIV testing as routine screening. Susan declines, saying that she and her husband were both tested shortly before their marriage 6 years ago, and that they have been mutually monogamous for 8 years.

Several weeks later, a new patient, "John Ruttley," presents to the practice and is scheduled to see Karen. The patient states he is concerned about a recurrence of thrush symptoms, a condition he was treated for 6 months ago. He states that he has been HIV positive for 5 years. He states that his wife knows about his HIV status and that they always have protected sex. He says that he has been receiving care from an infectious disease specialist in the larger town 100 miles away, where he works and lives 3 to 4 days a week managing a casino. He states that he called this specialist about the symptom recurrence, and he recommended that John seek immediate attention in his hometown.

Karen is stunned but maintains her composure and completes the visit with a prescription for an oral antifungal rinse and a recommendation to follow up with his infectious disease physician. After John leaves the office, Karen pulls Susan's chart and confirms that he is, indeed, the husband of the patient she saw several weeks ago.

 

The Nature of Ethical Dilemmas
This case scenario illustrates just one of the types of ethical dilemmas that nurse practitioners face in everyday clinical practice. An ethical dilemma is often described as a situation in which two courses of action are available and completely opposite each other, and for which a decision between the two choices must be made. Each opposing course of action is equally urgent, and each choice carries with it the sense that it alone is the right one.1

The very nature of ethical conflicts often makes any decision look like the wrong one. Dealing with an ethical dilemma can be particularly stressful for a new nurse practitioner. The ability to articulate moral distress when confronted with an ethical dilemma can make confounding cases like this feel more manageable. Ethical dilemmas present in every clinical specialty. As primary care providers, new NPs will find that, in addition to their medical responsibilities to provide care, they are also in new roles of authority and independent decision making.2

 

A Code of Ethics
Codes of ethics provide guidance about making morally sound decisions, but by their very nature, ethical dilemmas fall outside clear-cut guidelines for right and wrong actions.3,4 New nurse practitioners who are transitioning from RN practice may find that their new role contains more gray than black or white. Most also discover that familiar rules-based ethical codes are more applicable to RN roles and not very useful in NP practice. Some people argue that nursing itself is based in an ethics of virtue, and that moral wisdom flows from character traits that are developed within the discipline of nursing.5

Understanding the nature of ethical dilemmas and using skills taught in bioethics to deconstruct these situations may help NPs avoid engaging in self-recrimination. Understanding the process of ethical deliberation may facilitate acknowledging that you have done your best in difficult circumstances, and that moral wisdom, like clinical excellence, develops in time.6 But this self-acceptance may be especially hard for a new nurse practitioner who is trying to do his or her best and who may find it difficult to forgive choices whose outcomes are problematic.

 

Examine the Evidence
So, what can you do when faced with an ethical dilemma? A series of rational deliberations is necessary. First, examine the evidence of the case. In some ways, this is similar to the process of formulating a differential diagnosis. What do you know that could contribute to the decision, and what remains unknown that could contribute to a decision? How certain are you that all the presenting information is truthful? Might there be alternative explanations for some of the history that is presented?

Next, examine whether personal bias is factoring into your assessment of the dilemma. Emotional reactions are not necessarily wrong, but not acknowledging them and factoring them in rationally can be misleading. In this case example, there is a difference between an emotional reaction - such as personally identifying with the wife because of personal history with men who deceive their partners - and the emotional reaction evoked by the risk of a legal complaint that medical standards were violated (which could be brought by either John or Susan). Personal bias may exist based on religious or cultural beliefs, and if these are different from those of the involved parties, it is important to acknowledge the biases and not allow them to unduly influence the decisional process.7

Finally, consider any resources available to help examine and resolve the conflict. Is there a hospital affiliation with an ethics board or a university ethicist who would provide consultation?8,9


Ethical Dilemmas

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