Over the past decade with the progressions in modern medicine it has

Over the past decade with the progressions in modern medicine it has allowed individuals with co-morbidity health conditions to live longer and their care become more complex (Marshall 2006). Within today’s society individuals are more aware of the role of ethics and their own rights. (Welsh and Deahl 2002). Within healthcare the balance between treating patients and how ethically and lawful they can be treated becomes more complicated (Marshall 2006). In this essay it will explore how law and ethics are exercised when an ethical dilemma occurs within the healthcare setting. The patient in the scenario is a sixty- five-year-old male, the patients name has been changed for reasons of confidentiality in the essay he will be known as Barney (The Nursing and Midwifery Council 2018). Barney had been admitted after having a stroke. Barney had been assessed on admission and a nasogastric tube feed was inserted. However, Barney pulled it out on two occasions. The insertion of a percutaneous endoscopic gastrostomy feed (PEG feed) was discussed and he refused. The refusal of the insertion is where the ethical dilemma occurs. Barney was exhibiting signs of cognitive impairment leading to the questioning of his capacity to consent to the procedure. For full details of the scenario see appendix attached. This essay will follow how a decision to this ethical dilemma is concluded using ethical theories and principles as well as following laws and national guidance. There are three main ethical theories within healthcare; deontology, virtue ethics and utilitarianism, a form of consequentialism (Beauchamp and Childress 2001). Deontology focuses on duty-based ethics suggesting the action is only right if it is in accordance with moral duties and rules (Rhodes et al 2007). To decide which moral rules should be followed is done by using the reasoning of, individuals should behave in a way that can be imagined how all individuals should behave (Rhodes et al 2007). Deontology is difficult to apply in healthcare as the moral rules can be basic appearing unable to deal with the complexities of real-life healthcare ethical dilemmas (Mandal et al 2016). Deontology is subjective as everyone has their own morals and beliefs that would influence their perception of what moral rules are to be followed (Thiroux and Krasemann 2012). Virtue ethics concentrates on a person’s character and their motives (Crisp and Slote 1997). Virtue ethics proposes that the right action is one that a virtuous person would take (Crisp and Slote 1997). Like deontology virtue ethics is very subjective, as individuals will believe different actions makes a virtuous person (Thiroux and Krasemann 2012). Virtue ethics in this ethical dilemma is unhelpful as virtues are conflicting. It is virtuous to not insert the PEG feed as following the virtue of respect towards Barney’s autonomy however not inserted his health would be negatively affected causing him harm. The final ethical theory is utilitarianism it is a consequentialist theory and will be used throughout the essay to guide the decision made. Utilitarianism was founded by Jeremy Bentham (1748-1832) and John Stuart Mill (1806- 1873). Bentham (1748-1832) created the guiding principle for this theory ‘The greatest good of the greatest number’. Mills (1806-1873) went on to add that acts are right if they promote happiness, and happiness is classified as intended pleasures and the absence of pain. Bentham and Mills ideas were collaborated to create the consequentialist theoy that the action is right if it promotes the best consequences therefore maximising happiness and reducing pain (Bentham and Mill 1987). Philippa Foot (1985) wrote that the theory of consequentialism can be put into a basic formula of the actions taken and the consequences form a total outcome that can be judged right or wrong. This theorises out of all possible actions the right action is what has the best consequences (Foot 1985). Out of the three ethical theories consequentialism is the theory focused on in this essay as it can effectively be applied to the healthcare setting (Wheat 2009). Health professionals are faced with ethical dilemmas and ethical theories such as consequentialism gives a rational to the decision making (Wheat 2009). When applying consequentialism to the scenario within the essay the aim is to use the theory to discuss the possible actions for Barney and which would be deemed right according to the consequences the action produces. In an ethical dilemma, ethical principles can be used as a guidance to base the discussion. There are four ethical principles; autonomy, beneficence, non-maleficence and justice. In the scenario of Barney, the principles of autonomy and non-maleficence will be explored. Autonomy has many alternative descriptors; self- determination, freedom of will and liberty of rights (Leino-Kilpi 2000). The descriptors do not give enough detail how to apply autonomy to an individual. Scott’s (1998) definition suggests that autonomy is a quality of a person, instead of being a right they have. This definition is more universal as it embodies that every person is an individual with their own personality and beliefs that then formed their autonomy (Scott 1998). There is a person-centred approach to every action within healthcare, this approach would be respective of autonomy (Ekman et al 2011). Autonomy plays a key role in consent. Consent has become a fundamental part of modern medicine and ensuring the practice of patient centred care (Love and Pace 2018). Before every procedure can be carried out consent has to be gained (Love and Pace 2018). For consent to be valid there are three parts; the health professional must disclose all information regarding the procedure, the patient must be competent to be able to understand the information and voluntarily give the consent (lidz et al 1984). For Barney, the doctor explained the insertion of PEG feed providing him with the necessary information to give voluntary, informed consent. He then exercised his autonomy by refusing to give consent to the insertion of the PEG feed. However, the ethical dilemma was that Barneys competency was in questioning, and it was felt Barneys capacity should be assessed. Mental capacity is defined as the ability to use and understand information to compose a decision (Buchanan 2004).When health professionals are faced with decisions about capacity, The Mental Capacity Act (2005) is a statutory law that is used to protect individuals who lack capacity to autonomously make their own decisions and provides guidance for professionals to follow in the case of a patient lacking capacity. The core principle of The Mental Capacity Act (2005) is that an individual is assumed to have capacity until it is clinically established, they lack capacity (The Mental Capacity Act 2005). Barney was not immediately regarded as lacking capacity merely because he was making a decision that seems to be against his best interests. The decision to refuse the insertion only alerted the health professional to complete an assessment of capacity. The capacity assessment looks at cognitive ability, and if the patient can carry out the decision-making process. Certain conditions can interfere with these abilities in Barneys case the side effect of stroke. If Barney was deemed to have capacity and continued to not consent to the procedure, the procedure could not be carried out. If the insertion was completed without consent under The Mental Capacity Act (2005) it constitutes as battery and health professionals may face criminal prosecution. When a patient is found to not have capacity to make the relevant decision, then the health professional will act and make decisions in the patients’ best interests (Buchanan and Brock 1989). Best interests are a principle that provides guidance for health professional in the decisions regarding what actions to take for a patient who lacks capacity to make the decision themselves (Buchanan and Brock 1989). If Barney lacked capacity the health professional acting on Barney best interests would consider if the procedure showed clinically indicated, it should be completed. Also, it would consider which actions least restrict the patient’s future, any previous expressed decisions and any knowledge on the patient’s background (The Mental Capacity Act 2005). Within the decision-making Barneys friends and family would be consulted in order to gather more information that would aid determining the patient’s best interests (Nelson and Nelson 1995). Relating back to the theory of consequentialism in the case of Barney, respect for autonomy generally would generate the best consequences. If Barney had capacity and was able to use his cognitive abilities to give informed consent, then his decision would be final (The Mental Capacity Act 2005). However, if he lacked capacity his autonomous decision can be overridden, and the principle of best interests takes over. The principle of best interests correlates to the theory of consequentialism, as both are evaluating the scenario and making the best decision based upon which action provides the better outcome and least amount of pain. For Barney at first when he refused the insertion his competency was assumed therefore the procedure was not completed. After further assessment it was deemed through the effects of stroke, he did not have the capacity to make an autonomous decision. The health professional in charge of his care then had to act on Barneys best interests to make the decision if the feed should be inserted. Another ethical principle that can be used alongside autonomy in aiding the decision making in the scenario of Barney is non-maleficence. Non-maleficence’s main component is to do no harm (Beauchamp and Childress 2001). In the healthcare setting this can be applied to health professionals having a duty to do no harm to a patient or allow harm to occur through neglect (Dancy 1991). Non-maleficence is seen to be the ethical principle that is critical compared to other principles. Philippa Foot (1980) said that the obligation not to harm people is more imperative than the obligation to benefit people. Non-maleficence is like autonomy in that it is universal (Gillon 1985). It encompasses all individuals, professionals have a duty over all patients to do no harm. Whereas other principles such as beneficence are more specific, beneficence is a duty that is chosen to give (Gillon 1985). The health professionals in charge of Barneys care would act on the principle of non-maleficence. Looking back at the perspective of autonomy, there could a degree of psychological harm involved having his autonomy challenged. But by following the correct guidance from The Mental Capacity Act (2010) slight distress caused by the overriding of his decision would in the future of his care be in his best interests. In general terms of treating a patient who had suffered a stroke the National Institute for Health and Care Excellence (NICE) guidelines (2008) recommends that patients who are unable to maintain adequate oral nutrition or fluids should have an artificial feed initiated within 24 hours of admission. Further evidence that suggests an artificial feed should be inserted following the principle of non-maleficence comes from the Nursing Midwifery Council (NMC) Code of Conduct (2018). In the code it states that the fundamentals of care include nutrition and hydration. It goes on to state that those receiving care should all have equal access to nutrition and provide help to those who can not eat or drink unaided (The Nursing and Midwifery Council 2018). Under both the NICE guidelines (2008) and NMC code (2018) as well as applying the principle of non-maleficence providing Barney with adequate nutrition using an artificial feed would be the right action to take as it prevents harm occurring to Barney when not provided with nutrition and fluids. Not receiving nutrition and fluids can lead to malnutrition which is a serious health issue. It is estimated that up to 62% of patients who have had a stroke are malnourished (Foley et al 2009). Additionally, to providing adequate nutrition to Barney, the decision to insert the peg feed was related to his safety. More than 50% of stroke patients have dysphagia at the onset of stroke (Martino et al 2005). Dysphagia is the medical definition of swallowing problems, it can range from problems swallowing certain foods or liquids to being unable to swallow at all. Dysphagia puts the patient at risk of aspiration. Aspiration can cause serious health problems such as pneumonia (Martino et al 2005). To reduce harm to Barney occurring through swallowing problems, within the first twenty-four hours of his admission the nurse completed an assessment of his swallowing before he was given anything to eat, drink or oral medication to swallow (Scottish Intercollegiate Guidelines Network 2010). From this assessment Barney was referred to the speech and language therapists for a more detailed assessment (Scottish Intercollegiate Guidelines Network 2010). The outcome of the assessment was allowing Barney to orally ingest food and liquid would put him in harms way as he was a high risk of aspiration. Health professionals advised Barney to have PEG feed inserted. The PEG feed took away the risk of aspiration as the tube is passed through the skin and stomach wall directly into the stomach (O’Mahony 2012), supplying Barney with adequate nutrition safely. Each action that a health professional takes is considered with the principle of non-maleficence in mind (Veatch 2000). Consequential theory would propose by acting to minimise harm, the action taken would have the best consequences (Beauchamp and Childress 2001). The insertion of the PEG feed would provide Barney with adequate nutrition as well as prevent any further health problems caused by dysphagia. However, overriding Barneys autonomy even though it was established he did not have capacity could potentially cause Barney distress. The health professionals in this situation would have to evaluate which scenario causes the least harm and has the best consequences for Barney. Through using ethical principles and applying them to the consequentialist theory it has guided the ethical discussion. Throughout this essay the principle of autonomy has solidifies how important it is that every patient is treated as an individual who will make their own autonomous decisions regarding consent and their care (Leino-Kilpi 2001). In the case of Barney who did not have the capacity to make those decisions, by following the guidelines set out such as The Mental Capacity Act (2005) and acting on the nature of his best interests would have the best consequences. The principle of non-maleficence is the dominant principle in terms of best interest for patients. ‘Above all, do no harm’ is at the core of healthcare (Gillon 1985), when caring for Barney this principle was a complex part of the decision. For a decision to be made regarding Barneys ethical dilemma, the multi-disciplinary team discussed all the options available. Barneys family were also consulted. Collaboratively the conclusion made was Barney have the PEG feed inserted. The belief in this decision was that acting on behalf of Barneys autonomy the PEG feed was in his best interests and caused the least harm. Although PEG feeding is a more invasive method of artificial feeding it provides Barney with adequate nutrients and fluids, reduces the chance of aspiration and can in the future of his recovery be removed.

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