Step 1

Discuss whether this is an ethical dilemma? Discuss this case ethical issue. Using Two CNO Ethics Standard’s ethical values that or relate or conflict with the most to the case.  Also, provide the two ethical principles (from Lake Ridge handout) related to this case study.  Explain how each or principles or value apply to the case study.  Make sure s4 different values/principle are elected.

Walter’s case presents a medical dilemma for the physicians who are taking care of him at the hospital. For 14 years, Walter has been HIV/AIDS positive unknown to his relatives and friends including his brother who is Walter’s medical decision-maker in case of critical conditions. When Walter develops pneumonia and is admitted in the hospital, he categorically instructs the physicians not to divulge his HIV/AIDS status to his relatives or acquaintances. When his health deteriorates at the hospital, and he falls into a coma family and friends visit him at the hospital. His brother who is Walter’s medical surrogate needs information regarding his health to enable him together with the family to make informed decisions regarding Walter’s health. On the one hand, Walter, who is the patient, instructed the physicians not to reveal his HIV status condition to the relatives and he goes into a coma. On the other hand, Walter’s brother who is his medical surrogate needs all the relevant information concerning Walter’s health to make knowledgeable judgments on Walter’s medical needs while he is in the coma. Therefore, the case presents an ethical dilemma for the physicians between honoring the patient’s instructions to conceal his HIV/AIDS status from his family including his medical surrogate or to reveal the status to the brother who is the medical surrogate for him to make informed decisions.

The two CNO ethical standards that are in conflict in Walter’s case are client wellbeing and clients choice.  In the case of Walter, the client is the patient, Walter. Clients choice is becoming highly promoted in health care in that patient’s should and can play a primary role in decisions concerning their health. The promotion of clients can be seen in the continuing emphasis on patient empowerment, patient-centered care, informed consent and patients as partners in the medical care process (Zolkefi, 2017). The CNO ethical standard of client choice thus promotes the idea that Walters’s decision regarding his HIV/AIDS status should be respected and not disclosed to the family as he had instructed. On the other hand, client wellbeing in health care practice is also a primary focus and in case such as Walter’s attaining patient wellbeing may require discoloring of the information of his status thus creating a dilemma. Ethical practice calls for disclosure to the when it is in the best interests of the patients to next of kin who is Walter’s case is his brother identified as Walter’s medical advocate (Blightman &Griffins, 2013). At the same time, the disclosure of communicable diseases that could have caused death is required to be included in the death certificate (Blightman &Griffins, 2013). Therefore, it would be better for the brother to be aware before ant incidences. Thus, the regulations surrounding confidentiality and disclosure allow for the medical surrogate to access information where the patient is not in a position to give consent or make medical decisions.

The two LHO principles that regard Walter’s case are privacy and autonomy. Autonomy calls for respecting people’s choices and their right to make those choices and decisions regarding their health. Autonomy calls for the acknowledgment of a patient’s right and capacity to make decisions regarding their health. A client’s autonomy is the primary precedence in medical ethics, but it also acknowledges the place of family in the process of making health care decisions. However, the involvement of family is technical since although family intervenes with the best interest at heart, it can easily become excessively manipulative and coercive thus the need for care when disclosing information to the family especially against the patient’s wishes (Sedig, 2016). In Walter’s case, his decision is for his HIV status to be kept from his family and he made that decision before he went into the coma when he had the medical capacity to make the decision. Therefore, Walter’s choice and decision deserve to be accorded the autonomy advocates for by the LHO principles. The principle of privacy provides that individuals have a right to determine how, when and the extent to which information regarding their health should be communicated to others. Physicians should protect the patient’s privacy a principle that is promoted by the principles and standards of consent, confidentiality, trust and data stewardship (Canadian Medical Association, 2017). In the case of Walter, the doctors had a responsibility towards Walter who is their patient to uphold his instruction not to disclose his HIV status to his family.

The LHO principles and CNO ethical standards offer positions that make Walter’s case an ethical dilemma for the doctors. They have to decide between upholding patients privacy, autonomy and respecting his choices or promo0ting his wellbeing by making his Status known to the brother who is the medical surrogate so that he can make health care decisions on behalf Walter from based on substantial knowledge.

 

 

 

Step 2

Step 2a: Collect all information relevant.  Identify unknown and known evidence and facts. Consider the quality of life, medical indications, preferences, client safety, client’s capacity, legal, social, and economic factors.

 

The actualities of Walter’s case are several. Walter has been ill and aware of positive HIV status for over 14 years and has managed to keep the status of his family and friends. Even when his health deteriorates and he suffers from pneumonia he clearly instructs the doctors that his HIV status should not be disclosed to his family and friends. Walter has a medical surrogate; his brother who is also unaware of his HIV status. Walter goes into a coma and his brother as the medical surrogate asks the doctors questions so that he can be able to make informed decisions regarding Walter. Walter’s quality of life is poor, and his safety depends on the decisions made regarding his life and health at a critical time.

The medications indications for the case are clear that Walter is in a critical condition. Walter is HIV positive, has developed pneumonia which is a risk factor in HIV patients and his condition deteriorates to a point where he goes into a coma. Medical decisions will still be made for Walter in his coma, and his brother who is placed as the medical surrogate is responsible for making such decisions. Walter’s case presents an ethical issue because Walter has not disclosed his HIV status to his relatives and has asked his caregivers not to tell his relatives or friends about his HIV status. Walter is in a coma which compromises his capacity to make his medical decisions and thus lays the responsibility of his medical substitute.

 

 

 

 

Step 2b: Consider professional standards, guidelines, policies, relevant legislation and code of ethics related to this case study

A patient’s information privacy and confidentiality regarding their health are protected by federal and state laws which require health care providers to be careful in matters relating to collection and disclosure of patient’s information. Some of the laws that protect a patient’s information privacy and confidentiality include Personal Information Protection Act, and the privacy act among others (British Columbia College of Nursing professionals, 2018). According to the AMA code of medical ethics, patients are at liberty to decide the persons who can access their health information or who the health information should be disclosed. It proceeds to provide that physicians should notify the patients of any disclosures and in cases where the patients may harm themselves or are incapacitated, the surrogate should give consent for sharing (American Medical Association, 2016).

 

 

 

 

 

 

 

 

 

 

 

 

Step 3

Step 3a: Identify and Evaluate Perspectives and Responsibilities of stakeholders

Complete the chart provided considering the following for each identified stakeholder:

• What are their responsibilities (roles, obligations or duties) in this situation?
• Which of their beliefs, assumptions values, or goals will affect this decision?

 

	Responsibilities (Roles/Duties/Obligations)	Values (Beliefs/Goals/Assumptions)
Stakeholder: Walter as the patient	Making health decisions for himself and  decide who has access to their health information, duty to protect the health of others,	Protecting his family, protect the welfare of others, limit access to his health information
Stakeholder: Walter’s brother	To make health care decisions for Walter who is in a coma as the medical surrogate, duty to ask questions and inquire of any information relevant to making decisions regarding Walter’s care, respect Walter’s autonomy	To respect the patient’s independence, promote Walter’s wellbeing as the medical surrogate,
Stakeholder: Doctors in Walter’s case	To uphold client confidentially and privacy, respect Walter’s autonomy, provide the health surrogate, with relevant information to make informed decisions regarding Walter’s health, ensure Walter’s wellbeing as much as possible	Respect the patient’s independence and control over their health decisions, practice in accordance to the code of ethics and promote the standards of health care practice, promote patient-centered  health care, to create a trusting environment for the patient (De Bord, 2013)

 

 

 

Step 3b: Identify where conflicts exist by reflecting on the following questions:

• Do the responsibilities of one stakeholder conflict with others’ responsibilities or perspectives?
• Do the values, beliefs or goals of one stakeholder conflict with other’s responsibilities or perspectives?
• Do any stakeholders ‘perspectives hold greater weight/priority? Why?

The obligations of the stakeholders conflict significantly in Walter’s case. The doctors have to ensure clients wellbeing and at the same time protect his privacy by respecting his non-disclosure instruction. Walter’s brother has a responsibility to make medical decisions on behalf of Walter as the medical surrogate. To do so, Walter’s brother requires all the relevant information to make the medical decisions to the best interest of Walter. The doctor’s obligation to protect Walter’s privacy conflicts with the obligations of Walter’s brother to access Walter health information to make informed decisions. Doctors are limited in the amount of information they can offer Walter’s brother given Walters instruction not to disclose his health condition to the family. It was Walter’s obligations to protect the health of other conflicts with his right to privacy. His family especially if he has a wife should know of his HIV status to protect themselves. Walter’s perspectives have a greater priority since health care is patient-centered.  Patient-centered care is increasingly promoted as the primary approach to health care provisions, and it is built on the idea of making the health care system patient-driven (Delaney, 2018). The challenge for the Walter case is the fact that he is in a coma thus has lost the capacity to make health decisions.

 

Step 4

Examine and Come up with your values concerning the issues presented by this case, and how that might affect your perception of ethics?

My feelings towards Walter’s case were un-conflicted with a stance that the doctors should tell the brother who is the medical surrogate of Walter’s HIV status. The brother is the designated medical surrogate and thus deserves to know Walter’s condition given that he has lost the capacity to make his own medical decisions. I felt livid of Walter failing to tell his family and even requiring them not to be told of his status. The personal values that identify with this case are honesty, integrity, love, and care to and for the family as they have been taught to me by my parents growing up. We owe our families the truth regardless of how tough it may be. Walter would have been seeking to protect his family from the truth which indicates care and love for his family in his way. At the same time, Walter may have been ashamed or embarrassed to tell his family that he had HIV. The brother exemplified the value of care for his brother by asking questions to be well informed to make decisions regarding his health. The doctor typified values such as care, respect for Walter’s privacy and autonomy by keeping Walter’s status confidential has he had asked of them.  If the scenario is repeated, I will seek to clarify from Walter before his coma if his brother, as his medical decision maker, should be notified of his HIV status in case of his lack of capacity to make decisions to ascertain consent.  Therefore, it would be easy to resolve the ethical dilemma and tell the brother of Walter’s status while upholding his disclosure instruction with the other family members. Values and beliefs can be reinforced by being instilled from early stages of life and promoted and emphasized throughout one’s course of life to make them part of a person.

 

 

 

 

Step 5

Write out the issue/problem –simple, clear statement. Make sure the Identified problem is in terms of ethical values/principles

The problem in Walter’s case is that prior to his going into a coma, he had instructed his doctors not to inform his family of his positive HIV status, a secret he had kept for 14 years from his family. The doctors are thus ethically obligated to respect Walter’s decision as part of a patient’s autonomy and his right to privacy and therefore not tell Walter’s family about his HIV status. However, the brother who is the health surrogate for Walter needs to have all the relevant details to decide on Walter’s behalf in health care when he goes into a coma.

Step 6

Brainstorm all possible courses of action or options and for each identifies the Negatives/Consequences and Pros/Benefits. All possibilities should consider stakeholders.

Option	Benefits	Consequences
Uphold Walter’s instructions and not disclose his HIV status even to the medical surrogate	By doing so the code of the ethics and the standards are upheld through the respecting the patient autonomy and right to privacy.	Decisions regarding Walter health as made by his brother who is the medical surrogate will not be informed and thus may lead to poor choices in Walter’s care.
Disclose Walter’s HIV status to the brother who is the medical decision maker.	It will ensure that the treatment choices and health care decisions made by Walter’s brother on his behalf are well informed and thus the best options are made.	Walter’s right to privacy will be infringed upon, and it may raise legal and ethical issues when Walter gets better since he does give consent.

 

 

Step 7

Recommend a decision and justify/rationale for the decision. Take note of the full options analysis; provide the option best addresses the situation.

Walter’s health care providers should disclose his HIV status to the brother who is the medical surrogate so he can find an informed basis for the medical decisions he makes regarding Walter’s health. The doctors should, however, notify the brother that Walter does not wish for his family to know. Confidentiality in health care is not absolute as in some instances it is not valid. When cases of safety for third parties and public health become a matter of concern, confidentiality is not absolute (Noroozi, Zahedi, Bathaei & Salari, 2018). Also, breach of confidentiality is acceptable when the wellbeing of the patient and his best interests depend on it (Noroozi, Zahedi, Bathaei & Salari, 2018). By going into a coma, Walter in incapacitated and can no longer make his medical decisions and thus the surrogate is responsible for making those decisions, and he needs all the relevant information to make the right decisions. Disclosing the HIV status to the brother is to the best interest of Walter’s health.

 

References

American Medical Association (2016) chapter 3: Opinions on privacy, confidentiality and medical records. Retrieved on 1 March 2019 from https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/code-of-medical-ethics-chapter-3.pdf

Blightman, K., Griffiths, S. E., & Danbury, C. (2013). Patient confidentiality: when can a breach be justified?. Continuing Education in Anaesthesia, Critical Care & Pain, 14(2), 52-56.

British Columbia College of Nursing (2018). Privacy and confidentiality. Retrieved on 1 March 2019 from https://www.bccnp.ca/Standards/RN_NP/PracticeStandards/Pages/privacy.aspx

Canadian Medical Association (2017).Principles for the protection of patient privacy. Retrieved on 1 March 2019 from https://legacy.cma.ca//Assets/assets- library/document/en/advocacy/policy-research/cma-policy-principles-for-the-protection-of-patient-privacy-pd18-02-e.pdf

De Bord, J (2013). Confidentiality. Ethics of the Medicine University of Washington. retrieved on 1 March 2019 from https://depts.washington.edu/bioethx/topics/confiden.html

Delaney, L. J. (2018). Patient-centered care as an approach to improving health care in Australia. Collegian, 25(1), 119-123.

Noroozi, M., Zahedi, L., Bathaei, F. S., & Salari, P. (2018). Challenges of Confidentiality in Clinical Settings: Compilation of an Ethical Guideline. Iranian journal of public health, 47(6), 875-883.

Sedig, L. (2016). What’s the role of autonomy in patient-and-family-centered care when patients and family members don’t agree?. AMA journal of ethics, 18(1), 12-17.

Zolkefli Y. (2017). Evaluating the Concept of Choice in Healthcare. The Malaysian journal of medical sciences: MJMS, 24(6), 92-96.