CASE 1: Mrs. N, a 77-year-old married woman, has moderatelyadvanced Alzheimer disease, which causes periods of confusion,frustration, anger, and obsessive thinking. Before she became ill,Mrs. N and her husband discussed their wishes should anything happento them. Mrs. N told her husband that if there was no chance ofsurvival, she would not want to be hooked up to a breathing machine.They never got around to completing their advance directives. Mr. Nis devoted to his wife and wants her to receive the best carepossible. He has spent the past year watching after her, cooking forher, cleaning the home, and witnessing her deterioration. When Mrs. Nbecomes unable to walk alone safely, he allows the physician to admither to a long-term care facility. After three weeks in the nursinghome, Mrs. N starts to cough and becomes febrile. The doctordiagnoses pneumonia, begins IV antibiotics, and transfers her to alocal hospital. The pneumonia responds to the antibiotics, but Mrs. Nstops talking and refuses to eat. The physician calls her husband forpermission to insert a feeding tube. Mr. N wants to do what is bestfor his wife. He wonders if a feeding tube is similar to a breathingmachine. If she doesn’t want a breathing machine, would she alsonot want a feeding tube? Would it be possible for him to watch herdie of starvation? Is that murder? What would she want? What is theright thing to do?
Case facts and Analysis
In the first case, it is evident that Mr. and Mrs. N are great loversand Mrs. N is ailing from Alzheimer. The two couples share theirwishes. Mr. N tells her husband that any time her situation willworsen chances of her survival lessen, and thus she should never beplaced in a breathing machine. However, Mr. N loves her wife andalways finds the best care for her. Mr. N has spent most of his timetaking care of her and monitoring her situation. Mrs. N finallybegins to deteriorate. She is admitted to a hospital and placed in along term care facility. She gets diagnosed of pneumonia andtreatment begins. Later, Mrs. N stops talking and eating and herhusband is called by doctors to get permission from him to insert afeeding tube but Mr. N wants to fulfill her wife’s promise by notletting doctors insert a feeding or breathing tube. The problem is,should Mr. N go against her Wife’s wish and allow the doctors toinsert the breathing or feeding tube in her wife.
According to Utilitarian theories, no ethical activity (for example,“Keeping your promise”) is fundamentally wrong or right. Instead,the wrongness or rightness of a rule or an action is a matter of thegeneral non-ethical good (for example, happiness, pleasure, health,satisfaction, or knowledge of personal desire) produced as a resultof fulfilling that promise (Garner & Rosen, 2014).UsingUtilitarian rule, permission from Mr. N to let doctors insert afeeding or breathing tube in her wife will be a violation or theirpromise. This will in turn bring dissatisfaction to his wife if shehappens to recover because she didn’t want a breathing tube. Thoughletting her suffocate and die is immoral and doctors are aware ofthat however, according to Utilitarian theories on ethics,fulfilling your agreed promises that will ultimately make the otherperson satisfied is the best regardless of whether it is good or bad.Therefore, Mr. N should not allow the insertion of the breathing tubein her wife by doctors. Rather he should just allow her to restbecause maybe his wife didn’t want more pain and wanted to die toeradicate painful living.
CASE 2: Deborah is a nurse practitioner working in a privatelyowned primary care clinic. This clinic serves mostlyMedicaid-eligible families. Although Medicaid pays generously formost diagnoses and procedures, it often denies payment for wellnessservices. In order for the clinic to make a profit, it has become anunwritten policy to give every patient a diagnosis even if no problemactually exists. Deborah is reluctant to do this because sheconsiders this fraud. Her supervisor assures her that everyone elseat the clinic invents diagnoses, and not only is it common practiceacross the country, but it is a necessary practice to ensure that theclinic will stay open. The supervisor says that Medicaid policy isoutdated, and that inventing a diagnosis is the logical solution. Shealso implies that Deborah jeopardizes her job if she refuses toparticipate in this practice. The nurses in the clinic tell Deborahthat the supervisor is right everyone has been doing this for yearsit has never caused any problems. Deborah worries that if she refusesto follow the supervisor’s request, she may lose her job. She alsobelieves Medicaid really should be paying for the visits and that theclinic is a vital community service.
Is this an ethical dilemma, a legal problem, or both?
What principles are involved?
What are the legal implications for Deborah?
What are the legal versus the ethical implications of this situation?
How do you think Deborah should handle the situation?
Case facts and Analysis
In this case, Debora is a nurse by profession and she is employed ina private clinic that offers primary care services. This clinicattends only to Medicaid-eligible groups, and this service generateshuge profits for the majority of diagnoses and procedures. But thereis no payment for wellness services. Thus, for the clinic to generateprofits, it is their unwritten policy to invent a fake diagnosis forpatients even if they are problem-free. For that case, Deborah isnot willing to partake in this act because according to her, this isa malpractice. She is told that every other employee does this and itis this act that keeps the clinic running. The supervisor emphasizesto Deborah that this is the best solution because Medicaid is out offashion. Deborah is informed that she will be risking her job if sherefuses to get involved in this activity. The nurses as well agreewith the supervisor and tell Deborah it has never brought any problemever since. Deborah worries that her job will be lost if she fails todo what other nurses are doing and she wants to know the best way forher to take.
This is an ethical dilemma and at the same time, a legal problem.According to deontological theories, any act that may bring adiscontentment in you after fulfilling such an act is an immoralactivity (Lefkowitz, 2003). Deborah believes that by getting involvedin fake diagnosis, she is committing fraud and this has legalconsequences if it gets into the hand of law enforcement agencies.The legal implications are that, Deborah and the whole institutioncan be sued because of formulating fake diagnosis. In such instances,patients are given treatment for diseases that are not available andthis can harm their health.
There are also ethical principles violated in this case study, thefirst is the principle of Beneficence, which implies that everyonehas a duty to bring about good in any activity s/he is involved in(Beauchamp & Childress, 2001). Thus, Deborah is right in refusingto get involved in inventing fake diagnosis to patients. This isbecause it is an unprofessional conduct and will affect the health ofpatients in the long run. Autonomy is the second principle violatedin Deborah’s case. This principle states that it is our duty torespect the independence of other people (i.e, their choicesconcerning their lives) (Bowne, 1892). In this case study, thesupervisor should let Deborah settle on her decision of refusing toparticipate in inventing fake diagnosis for patients because it isfraud according to her. She is firm in doing what is right so doctorshould not compromise her stand. Justice is the last principle inDeborah’s case, which demands that we have a duty to give otherswhat they deserve (Beauchamp & Childress, 2001). In this casestudy, the patients are paying for treatment of illnesses that do notexist. This is not justice at all. They should be diagnosed and toldthe truth rather than extract money from them, which they ought notto pay.
Since inventing fake diagnosis just to make profit is a malpractice,Deborah should stand her ground and refuse to participate in theiracts even if it means losing her job. She should even quit from thatclinic because such acts will have legal consequences. Deborah shouldseek another job where there is work integrity.
Beauchamp, Tom L., and James F. Childress. (2001). Principles ofbiomedical ethics. New York, N.Y.: Oxford University Press.
Bowne, Borden Parker. (1892). The principles of ethics. NewYork: Harper & Brothers.
Garner, R. T., & Rosen, B. (2014). Moral philosophy: Asystematic introduction to normative ethics and meta-ethics. NewYork: Macmillan.
Lefkowitz, J. (2003). Ethics and values inindustrial-organizational psychology. Mahwah, N.J: LawrenceErlbaum.