An Ethical Incident from My Nursing Career

Nurses represent the largest community in the health system. At the same time, they are the closest to the patients among all health care providers. Furthermore, nurses’ roles contain a lot of interaction with patients. This interaction hides huge potential possibilities for them to face moral situations. In addition, moral situations usually have a complex nature. For all that, nurses should be prepared with knowledge and critical thinking skills to be able to make sound moral decisions. This paper discusses the ethical dimensions of an incident. The incident presents the conflict nurses usually face during and after making a paternalistic intervention. The aim of this paper is to discuss the ethical issues related to the paternalistic interventions in the light of the suitable ethical theories in the


Introduction
Nurses represent the largest community in the health system. At the same time, they are the closest to the patients among all health care providers. Furthermore, nurses' roles contain a lot of interaction with patients. This interaction hides huge potential possibilities for them to face moral situations. In addition, moral situations usually have a complex nature. For all that, nurses should be prepared with knowledge and critical thinking skills to be able to make sound moral decisions. Moreover, ethical decision making is not a stress-free task. It needs courage and ability to handle the related responsibilities and consequences. In this paper, I am going to discuss an incident which happened with me during my nursing career. The reason behind choosing this incident is related to its ethical dimensions.

The Incident
It has been a long time since the incident happened. Yet, its memory remains very clear in my mind as if it had been happened yesterday. This is due to the fact that the ethical decision which I made affected my patient's life and my career. The incident took place, ten years ago, at a hospital in a developing country which I had been working for. A patient had a car accident and had been transferred to the emergency unit. He was semi-conscious, confused, and very pale. Apparently, he had lost a lot of blood. The doctor ordered me to transfuse three units of blood to him and to prepare him for operation. The patient was unable to make judgments. For that, I was forced by work place regulations to obtain the consents from his family. Thus, I asked his parents to sign the informed consent, after explaining the importance of the procedure. The unpredicted response was that the parents refused to sign the consent for the blood transfusion, while accepting consenting for the operation. Directly, I reported the situation to the doctor. The doctor asked me to continue with the blood transfusion regardless of the parent's opinion. The doctor justified that as it is the only way we have to save the patient's life. I decided to carry out doctor's order, but after a final attempt for the parent's acceptance. The parents become irritated from my request and continued refusing. The blood transfusion conflicted with their religious beliefs. Therefore, I moved the patient far from their eyesight and started the blood transfusion. After that, I shifted him to the theater. Three hours later, the patient came out from the operation in an entirely better status. The parents were extremely happy.
Reviewing this incident, I wondered about what I did that night. I like to consider my decision ethically justified. However, I was not sure about my own feelings that night. I felt happy because the patient became stable. At the same time, I felt a dire need to justify my paternalistic intervention. Moreover, I felt guilty because I breached the rules of my work place. The following discussion kept reoccurs in my mind; however this is the first time it has been written.

A Discussion through Chosen Ethical Approaches
The main ethical issue in the incident is basically related to the correctness of the paternalistic intervention taken. One more ethical issue is related to the breach of the work place regulations which I made. The right way to discuss these issues is to analyze them in the light of the suitable ethical theories in the literature. Thus, I am going to discuss these issues from the perspective of each applicable ethical theory on the incident.
First of all, Lawrence [1] stated that "Principlism provides a working set of tools that are used every day in modern health care."(p. 40). Thus, the Principlism theory by Beauchamp and Childress seems to be a good start for the discussion. In the incident, I choose to override the parent's decision for the sake of ensuring the beneficence and ensuring the non-maleficence for the patient. However, I justified that by two reasons. First, the parents stated their order according to their own beliefs, whereas the patient beliefs were unknown to me. Hence, the patient's beliefs may differ from his parent's beliefs. Second, the incident matched the criteria for applying a paternalistic intervention which suggested by Benjamin and Curtis [2]. Initially, the parents were under stress. Thus, it seems appropriate to say that their rational judgment were significantly impaired. Next, the patient was in his way to eminent death without the blood transfusion. Also, it looks suitable to assume that the ratification condition was applicable. For all that, the paternalistic act seemed proper and reasonable to me. Thus, deciding to override parent's decision was essential to achieve the beneficence and the non-maleficence for the patient. Many people supported my decision. However, the administration in the hospital did not. The administration saw my paternalistic intervention as a clear penetration of work polices, and I received a warning. In conclusion, the Principlism may be considered as a useful set of tools in ethical decision making [1]. In spite of that, it seems proper to say that it is not really an effective way. That is due to the fact that unquestionable decisions cannot be made through it. Moreover, using the Principlism approach to make unquestionable decisions is very hard in emergencies; due to the lack of the time in such cases.
Second and third, the Consequentialism and the Utilitarianism ethical theories which I choose to discuss the incident from their perspective together, due to the strong relation between them. Initially, the Consequentialism theory holds a core concept that the consequences of one's behavior are the crucial basis for any judgment about the correctness of that behavior. Thus, a morally right act is the act which will produce a good consequence. Similarly, the Utilitarianism theory holds a core concept that the greatest happiness of the greatest number of people can validate the ethical decision. The basic aim of Utilitarianism is to maximize happiness and to reduce suffering. John Stuart Mill [3] explains that the actions consider right as they tend to promote happiness, and consider wrong as they tend to produce sadness. Using the perspective of both theories together, I can say that moral decisions are those decisions which they promote happiness by their good consequences for the largest number of people. Keep in mind that decision making is basically a selecting process between alternatives. Thus, the alternative which ensures a higher probability of happiness for a larger number of people is the ethical alternative. For that, it was the right decision to be made. Therefore, the paternalistic decisions seem good ethical decisions. This is due to the fact that health care professionals are more knowledgeable about the consequences of the decisions related to health. That makes them more able to choose the right alternatives and to make the right decisions toward patient health. However, this conclusion maybe considered questionable due to the persistent debate over how much consideration should be given to the intended consequences from the decision. That is comparing with the actual consequences from the decision. This questioning may be answered through the concept of the foreseen results. The foreseen results stand in between the intended and the actual results. The foreseen results are basically a logical estimation about the probability of achieving the intended results from the decision made. This supports the morality of the paternalistic decisions, due to the fact that health care professionals are more able to estimate the probability of achieving the intended results. For all that, it seems proper to say that my paternalistic decision was an ethical one from the perspective of both theories. This conclusion has two reasons. First, I rationalized that the parent's happiness for their son survival will certainly overcome their sadness from overriding their beliefs. Besides, this definitely will increase the total happiness of society. This corresponds with the core belief of the Utilitarianism theory. Second, I considered that one patient will remain alive is better than him turning out dead. This corresponds with the core belief of the Consequentialism theory, as it is undeniably a good consequence from the decision. Furthermore, the logicality of my decision seemed clear. That is depending on the vast probability for saving the patient's life as a result for transfusing the blood. Apparently, that was a correct foreseen result which turned out to be an actual result. In fact, it seems proper to say that the Consequentialism and the Utilitarianism theories seem helpful approaches to reach justifiable ethical decisions if they emerged together.
Forth, Professionalism theory seems an appropriate ethical theory for discussing the incident. Professionalism theory is constructed on a principle that any practice in which happiness is sacrificed for success is professional practice. In nursing, Professionalism is an attitude of nurses that keeps patients above any external factors. It is a commitment to compassion, to caring, and to strong ethical values [4]. Therefore, it seems rational to consider that the Professionalism theory has no conflict with the paternalistic decisions. This conclusion is due to the fact that the paternalistic decisions are those decisions which health professionals take to ensure the beneficence of their patients. The aim of the paternalistic decisions is basically to succeed in saving the patients' lives. This is the golden ethical aim for all health care professions. Thus, it is suitable to consider any professional act toward that aim an ethical act. Furthermore, the responsibilities of those decisions are a burden which usually affects the happiness of the health care professionals. However, there may be an objection related to that. This objection is mainly related to the different definitions for the Professionalism adopted in each work place and in the varied schools of thought. In spite of that, professional acts should always aim for the beneficence of the patients. Otherwise the morality of the professional acts will be compromised. Finally, it seems appropriate to say that my practice in the incident was a professional one. This is because my decision was compromising my career and my career is a fundamental basis for my own happiness. In addition, my decision was focused on achieving the success in saving my patient's life.
Lastly, the Deontological theory is the fifth ethical theory in which I will discuss the incident through. Deontological theory looks at inputs rather than outcomes; denotes that the morality of the acts is measured by its adherence to rules; states that the right is prior to the good. Thus, it seems that the paternalistic interventions are conflicting with the core concepts of deontology. However, this conclusion is not supported by all deontologists. The argumentation between the deontologists about whether too bey the rules all the time or to breach them sometimes for the sake of achieving the beneficence of the patient is persistent. In order to clarify that, I will apply Kant and Ross deontological approaches on the incident. Thus, by implementing Kant's perspective on the incident the result will be that I made a wrong ethical decision. From Kant's perspective, adherence to rules is the way to keep unified treatment for everyone. This provides justice and increases trust in nurses. This can only be achieved by obeying work policies. In contrast to that, implementing Ross's perspective on the incident the result differs and my ethical decision becomes right. From Ross's perspective, we have a prima facie duty not to make paternalistic decisions, unless those decisions are obligatory to accomplish the stronger duty of saving the life of our patients. Therefore, I can depend on Ross's perspective to justify all the paternalistic decisions including mine. However, it seems more appropriate to say that Deontological theory does not provide a clear judgment about the morality of the paternalistic decisions. This is due to the constant argument between the deontologists about the morality of those decisions.

Conclusion
At the conclusion of this paper, there are two questions which entice my mind. Are ethical theories effective in practical life? Besides, can we rely upon them to make or even justify ethical decisions already made? In fact, it seems that one of the possible answers to both questions is: "not always".The reason behind this answer is due to the fact that the probability to reach justifiable ethical decisions using those theories is auxiliary low. Moreover, the decisions made depending on those theories are not peremptory and are always questionable. However, this is basically related to the nature of the ethical decisions. At the same time, it is related to the deficiency in the practicality of the ethical theories which we have. Definitely, we cannot change the nature of the ethical decisions. Thus, it is necessary to make adjustments to the ethical theories in order to make them more contextually practical. As a final point, until this happens it seems that the difficulty in making unquestionable justified ethical decisions will always exist [5][6][7].