Clinical Law and Ethics

“You are working is a casualty department of a large hospital. An accident victim is rushed in one evening. He is conscious, but badly injured and desperately in need a blood transfusion. However, he turns out to have religious principles that forbid the exchange of blood. You explain the situation to him, including the very real threat to his survival if he does not have a transfusion. He clearly understands exactly what you are telling him, but still refuses to accept a transfusion, and asks you to do what you can by other means. He then slips into unconsciousness. One of your colleagues suggests that you give him a transfusion while he is unconscious, thereby saving his life.”

Introduction

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This paper will explore the difficulties a Nurse would have to face in this situation and come to conclusions as to whether the blood transfusion should be given, following the law and other ethical frameworks.

For the purpose of the paper there will be a focus on Beauchamp and Childress’s four principle approach which includes;

1. Respect for autonomy;

2. Non-maleficence;

3. Beneficence, and

4. Justice.

The paper will include personal views surrounding the subject and also legal and ethical views put in place by the NMC. Views will be enforced by further reading and research. This will then lead to a final conclusion to the dilemma in question.

Autonomy

Autonomy can be described as self-governance and independence of thinking. It has been argued that to be autonomous, one must have the mental capacity to make an informed, uncoerced decision, about ones health.

There are three aspects to autonomy;

1. Thought – thinking for oneself

2. Will – freedom to make decisions on your deliberations

3. Action – freedom to act on ones will and deliberation

These aspects of autonomy must be respected at all times without judgement of character.

The victim of the accident is autonomous in this case as he is an adult who can make an informed decision, after being told the risks of not having a blood transfusion, think idependently and make an uncoerced choice about his faith. However, it could be argued that the patient was not autonomous due to the accident and that his mental capacity had been impaired, maybe by some head injury. There are other limitations to autonomy and these include; legal rules and regulations, religious beliefs, social staus and family connections and beliefs. These aspects can impair a persons autonomy.

Tschudin (2003) suggests that many Jehovahs Witnesses are “too often made to feel inadequte or even like criminals” if they follow their own faith and refuse treatment. This can also compromise autonomy of the patient, coersing them into making a decision which does not comply to their religious beliefs. The Human Rights Act (1998) links in with Tschudin’s theory and states “The enjoyment of the rights and freedoms set forth in this Convention shall be secured without discrimination on any ground…”.

Non-maleficence

Non-maleficence is the duty to avoid harming the interests of others. This would involve the Nurse listening to the patient’s beliefs and wishes and granting them to the best of her professional ability.

Non-maleficence can be hard to follow if the Nurse does not believe it is morally right, in her opinion, to do so. If her interests, in this case, were to save the patients life, she would give the blood transfusion, thus compromising the patient’s wishes. However, Frankena (1973) argues that if looking after a patient, their interests and their right to be non-maleficent should come first.

Beneficence

This includes doing “good” for others and promoting patients needs, thus protecting them at their most vulnerable. This would involve asking the patients permission to perform a procedure and complying with their wishes. However, if a patient is able to communicate their needs, beneficence can be hard to achieve. Beneficence can be a positive attribute when, for example, the health care professionals act as advocates for patients whose autonomy is limited. In this case it would be up to the Doctors to decide what was best for the patient.

Even though the patient in this dilemma has fallen into unconsciousness, he stated his wishes before, so this must be followed therefore, protecting him in terms of his religion.

Again, a Nurse could find this difficult to do as they may believe protecting the patient at their most vulnerable, is saving their lives by giving the transfusion. A Nurse in this situation would have to think critically about her job and the patients beliefs.

Justice

Thiroux (1995) describes justice as an “attempt made to distribute the benefits from being good and doing right.”

When the patient lost consciousness, the notion of justice became urgent. The decision to do good for the patient or the decision to do right for the patient. There is a very fine line between the two. A Nurse could see that doing “good” for the patient is to save their life, but to do “right” is to follow their wishes and beliefs.

Dimond (1999) describes a case of a Jehovah’s Witness, aged 57, who was seriously injured in a car accident and urgently required a blood transfusion. He held a card stating his religious beliefs and that he should not undergo a blood transfusion under any circumstances. This is the same with dilemma stated above. The surgeon caring for the man decided that, regardless of the mans wishes, the blood transfusion should go ahead. Fortunately the patient survived his accident; however, the surgeon who saved his life was taken to court and sued.

A spokeswoman from the British Medical Association told The Times: “The doctors’ hands are tried. Competent adults have the right to refuse any medical treatment even if that refusal results in permanent physical injury or death…you can’t force someone to. To do so would be against the Human Rights Act.” This proves that in a court of law, the patient’s wishes would outweigh the beliefs of the medical staff.

When a medical professional is unable to perform a blood transfusion, they should try and find alternative or complementary therapies to aid the patient to have a better chance of survival. The American Cancer Society (2006) states that “blood substitutes are experimental and are rarely used. They may be used as a temporary measure in patients whose religious beliefs do not allow them to have blood product transfusions.”

The Human Rights Act (1998) states that individuals who believe their human rights have been breached to take legal action against the authority. In this case, if the blood transfusion was given, it would be quite easy for the patient to sue the Nurses and Doctors involved for breaching their right of religion and right to refuse treatment, even if it results in death.

Most relevant to this dilemma would be Article 9: Freedom of conscience. This article states that “Everyone has the right to freedom of thought, conscience and religion.”

Conclusion

In conclusion, all of the information above has been researched and it is clear to see that the patients rights must come first, regardless of personal beliefs and view. Patients must be treated as individuals despite their own beliefs and religious views. If a patient is fully capable of being autonomous, they should be treated as such and should not be persuaded to change their views.

In any case, it is difficult to understand religious views that we ourselves do not follow, but as health care professionals must do so.

It is important to remember the NMC code of conduct when faced with dilemmas such as this and it is important as a professional to follow this; “When facing professional dilemmas, your first consideration in all activities must be the interests and safety of patients and clients.” Simply, the patients interests comes first. As health care professionals we must respect all diverse religions and beliefs and learn that, even though it may be against what we believe as individuals, clients rights are paramount and should not be over-ruled unless autonomy is impaired.

Taking into consideration, ethical, moral and legal frameworks in this scenario, the blood transfusion should not be given, thus complying with the rights of the patient and the NMC code of professional conduct.