Dignity
One of the ethical issues that is significant in the case of Mr. S, is the proposed ankle wander guard as preventive fall measurement. Considering that Mr. S is recovering from an accident and a stroke episode and has also fallen two times in past 3 days attending to reach the bathroom at night, the ankle wander guard seems as a reasonable precaution against future injuries. In addition, there is also limited staff to monitor Mr. S in the room overnight. As a further matter, Mr. S is reluctant to require ambulatory assistance by pressing the aid button, making the ankle wander guard a plausible solution to prevent other falls. However, Mr. S is refusing the use of the ankle wander guard. Even though we know it is a measurement that ensures Mr. S’ safety, placing the device against his wishes, makes it an ethical issue. On the one hand, it will benefit the recovery of Mr. S by preventing fall injuries, but on the other hand, it threatens his patient’s rights.
The ethical principles that should be considered when developing a plan to address the nighttime ambulation of Mr. S are dignity, autonomy and beneficence. When presented with the preventive measurement, Mr. S totally refused to the idea of using an ankle wander guard and expressed being treated “like an animal with a shock collar.” This feeling directly related to his sense dignity and worthiness. Dignity is the ethical principles concerned with the values and sense of worthiness that guides individuals’ feeling, actions and thoughts ( Baillie8). When illness develops, dignity is kept intact by holding certain perspectives including sense of control or autonomy, self-esteem, maintaining of self-identity, having optimistic spirit and feeling worthy of respect (2). The other principle that can guide the medical team in this case is autonomy. Autonomy is the ability of individuals to make independent decision related to their welfare (Yeo 91). Even though Mr. S does not satisfy all the four components of autonomy to exert himself, due to his limited-decision capacity, his autonomy right is still protective through the advance care directive or default surrogate, like in this case. The surrogate has the responsibility of making medical decisions that the patient would have made if capable and not on the surrogate’s personal preference (Pope 1077). Therefore, the medical team should seek help from the surrogates when making a health care decision. The third principle that should be considered in this case is beneficence. Beneficence entails not causing harm or acting toward the benefit of an individual (Yeo 103). In this case, beneficence should serve as a guidance to determine the harms associated with placing or not the device.
In the case of Mr. S, I recommend the team not to place the ankle wander guard against his will. Since the free action of Mr. S was impaired by the stroke as well as his free deliberation and moral reflection to make rational and coherent decision, he has limited-decision capacity. However, he is still granted the right of autonomy through a default surrogate, which in this case is his sister. If patients have not filed an advance directive or do not have a living will, the priority is given to patient’s spouse, an adult child, parents, or an adult sibling (Pope 1076). This implies that the medical team must turn to the sister for medical decisions. Although the sister agrees with use of a wander guard, she objects to placing the devices against her brother’s wishes. The medical team describes the sister as “loving, supportive, involved, and a reasonable, careful decision maker.” Therefore, considering that she has been granted the rights to make medical decision on the behalf of Mr. S, and that she is a diligent and rational decision maker who probably knows what her brother would have wanted if fully competent, the medical team should respect her decision.
As a further matter, violating his autonomy by placing the device also threats his dignity. Dignity applies to individual to same extent on whether or not these have or lack capacity (Baillie 8). It is conserved by maintaining certain perspectives such as self-control and self-identity, feeling of worthiness and respect and having an optimistic attitude (2). It seems that these are the perspectives that Mr. S is fighting to maintain. He has portrayed himself as an independent and fully capable individual regardless of his actually capabilities; he is persistent on using his walker to go to the bathroom instead of using a bedpan. Mr. S would rather take the risk of walking without assistant than peeing on himself or using a bedpan. These attitudes can be possibly tied to his self- identity and sense of worthiness. Mr. S expressed being treated like an animal when proposed with ankle wander guard. As a result, placement of the device can diminish his sense of independent and self-image. These could otherwise play a role in his rehabilitation process. Therefore, his dignity must be respected and conversed by not placing the device.
Even though honoring his autonomy and dignity might be the right approach, there are some risks associated with this decision. This is explained by the principle of beneficence. As defined previously, beneficence simply means not causing ham or acting on the best interest of an individual. In this particular case, there are limited hospital resources and staff that can monitor Mr. S overnight. Therefore, if the ankle wander guard is not placed, the staff cannot immediately assists Mr. S and he would be more susceptible to have a fall with more serious injuries and probably irreversible health problems. This action is totally against the consequential principle of beneficence in which skills and knowledge are applied to produce benefits (Yeo 109). Although, violating his autonomy and dignity can also add stressors to Mr. S’ recovery. Emotional stressors that could be as damaging as a fall. Moreover, attaching the wander guard against his wishes, can diminish Mr. S’ cooperation with the medical team and be counterproductive to his recovery, rehabilitation and treatment response.
Sources:
- Baillie, Lesley, et al. Defending Dignity- Challenges and Opportunities for Nursing. London, the Royal College of Nursing, 2008, p. 8.
- http://www.dignityincare.ca/en/the-model-in-detail.html#model
- Yeo, Michael, et al. Concepts and Cases in Nursing Ethics, Autonomy. 3rd ed., Ontario, Broadview Press, pp. 91-97, 103-109.
- Pope, Thaddeus M.Legal Fundamentals of Surrogate Decision Making. Minnesota, American College of Chest Physicians, 2012, pp. 1074-77.
- Yeo, Michael, et al. Concepts and Cases in Nursing Ethics, Beneficence. 3rd ed., Ontario, Broadview Press, pp. 103-116.
