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Ramón Ortega, a 42-year-old farm laborer with a history of hypertension, had been experiencing headaches on an almost daily basis for 2 to 3 weeks

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Ramón Ortega, a 42-year-old farm laborer with a history of hypertension, had been experiencing headaches on an almost daily basis for 2 to 3 weeks. Disturbed by the persistent and severe nature of the headaches, he visited the remote northern primary health clinic serving his northern rural community. Ms. Tracey Anderson, expanded role registered nurse and sole staff member of the clinic, listened as Mr. Ortega described his headaches. She then performed an initial examination, which revealed good general health with the exception of an elevated blood pressure of 190/108. Since Mr. Ortega had described some dizziness and visual disturbances during his headaches, Ms. Anderson also completed a neurologic assessment. Everything seemed within normal limits except for Mr. Ortega's peripheral vision. Ms. Anderson's assessment demonstrated that he had some difficulty seeing objects in the visual field on his left side. Ms. Anderson realized that this disturbance was probably a manifestation of his present headache in combination with his known visual deficit. Since no other abnormalities were demonstrated, the possibility of a more serious problem seemed remote, according to Ms. Anderson's judgment. Yet Mr. Ortega was very distressed by his headaches. He asked the nurse what he could do to prevent the headaches or, at least, what could be done to lessen the pain he was experiencing. Could she be sure no other problem was causing the headaches?

A few months ago, Ms. Anderson would not have hesitated to refer Mr. Ortega to the local hospital, 100 km's away, for an examination by a physician and a neurologic evaluation of his headaches. She would have done this for no other reason than to relieve the patient of his worry and to confirm the absence of a more serious problem. She still believed that, on balance, the referral would be of some help. In recent weeks, however, the provincial government through the LHIN (that funds the rural health clinics) had urged all health clinic personnel to be careful in referring patients for costly laboratory or evaluative testing and in incurring the added expense of clinic-sponsored transportation. There was decreased funding to support the personnel and services in the northern rural health clinics and all centers were being asked to be vigilant about extraneous costs.

Ms. Anderson has worked hard with the community leadership to cut the operating costs of the clinical without jeopardizing patient safety. In particular, they have decreased the referral of patients to the hospital unless there were diagnostic criteria to support the transport and a physician on the other end agreed. However, she cannot overlook the fact that Mr. Ortega is very distressed by his headaches, and there was always the possibility, albeit remote, that he was presenting with early signs of impending cerebrovascular disease, the effects of which could seriously affect him and his family. She is uncertain about what choice to make.

Commentary

The healthcare costs and decreased funding has generated pressures on health professionals such as Tracey Anderson to be conscious of the socioeconomic impact of their decisions. Some cost-containment decisions by nurses can be made without moral dilemma. Some procedures may turn out to be useless or even detrimental, on balance, to the patient. If the procedure under consideration is going to hurt the patient more than it helps, it is simply good nursing practice to eliminate it. If money is saved in the process, that is a fortuitous side effect.

If the procedure is one where the benefits and harms for the patient are just about equally balanced and if the patient has no strong preferences for the procedure, then the fact that it would be costly for the health clinic might plausibly be good reason to avoid doing it. In such a case, there is no good reason to go ahead. But Ms. Anderson's dilemma is more complicated. She has concluded that, on balance, Mr. Ortega would be helped by a referral for a neurological workup. It would at least provide psychologic comfort, and there is a chance that therapeutically beneficial information would be revealed.

Moral traditions have almost all included within their lists of ethical principles some sense of moral obligation to do good for other people or "to promote beneficence," as contemporary philosophy would state it. Ms. Anderson senses that beneficence is what is at stake here. She has a responsibility, in the words of the CNA Code of Ethics for Nurses, to promote "the health, welfare, and safety of all people." She has correctly perceived, however, that in this particular situation benefit for the patient and benefit for other people may well be in direct conflict. To make matters worse, the members of the public most likely to benefit directly from Ms. Anderson's cost consciousness are other patients in her rural health clinic area. The funds conserved by judicious compromise of Mr. Ortega's interests will be of benefit to other patients whose welfare she is also obliged to serve.

Two major options seem to be open to her. First, she could take the CNA Code of Ethics for Nurses, conclusion that "the nurse's primary commitment is to the health, well-being, and safety of the patient" and apply it rigorously to the patient standing before her. If the patient's well-being is primary and she has concluded that, on balance, he would benefit from a referral, then her moral dilemma is solved. Concern for the welfare of others is morally subordinate to concern for the welfare of the individual. If that moral priority is chosen, following the provinces directive to be cost conscious in such situations would be morally unacceptable. Of course, from the standpoint of the province, someone has to be concerned about the welfare of society. Therefore, they could impose constraints on Ms. Anderson for the kind and number of referrals she could make. In certain special, marginal cases, she might not even be permitted to make a referral even if she thought it was in her patient's (marginal) interest.

Ms. Anderson's other option is to abandon the notion that the well-being of the patient always takes priority over the public welfare. That would permit her to take into account the impact of her decision on the welfare of others—the province, taxpayers, and her other clients. She might, from this perspective, try to produce the greatest good by taking the welfare of all into account. She could strive for the greatest good for the greatest number, to use the classical utilitarian phrase.

There may be other options open to Ms. Anderson, options that would permit her to take into account certain benefits to society, but not others, when she decides whether morally, she should put the care of her patient above all other considerations. The balancing of the two kinds of interests might depend, for instance, on whether promises have been made either to her patient or to the province funding her clinic. It might depend upon how she, her profession, and society see the role of the nurse. It might depend upon the relative urgency of her patient's needs and the needs of others who might be helped with the funds. Any of these factors might be seen by the nurse, the profession, patients, or others in society as morally relevant, in addition to the amount of benefit and harm involved. The problem of how benefits to the patient relate to benefits to others is the first major moral issue confronted in many ethical situations in nursing.

 

 

Using the above information, apply this scenario to the ethical decision-making framework:

1)Individually Reflect on the case and the commentary. Write down your initial thoughts/reactions.

 

2)Determine who is involved in the case. Name all the parties and their relationship to the patient.

3)Describe the issue. What exactly is the problem or issue to be solved?

1. Assess the situation. What is the team's "perceptions" and reflections on the situation - in short form?
2. Clarify values. What Ethical Values are involved in this story?
3. Identify ethical principles involved in the case. You can use all your reading and resources to name them.
4. Clarify legal rules. Are there any laws involved in this story?