Ethical Decision Making in Healthcare: A Case Study

This case study explores the ethical decision making process in healthcare through the example of an elderly patient with a terminal illness. It discusses the principles of truthfulness, beneficence, and autonomy in healthcare and how they apply to this case. The patient's request for mercy killing is also examined in light of ethical considerations.

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Case study
Mr. Robert, an 85-year old African American man with a history of falls and dementia is
presented to the emergency department with a bad fall this time resulting to a kneecap
fracture. . He is accompanied by his two sons to the hospital that needed to foresee his
treatment. Upon admission, Mr. Robert complained of so much pain around his knee joint and
muscles of his right leg and was put on pain relieving medication, acetaminophen while he
waited for the physician to monitor his knee. After a couple of hours, he was assessed and the
physician pointed out that he needed a kneecap removal since it was damaged beyond repair.
During all this period Mr. Robert was already hysterical and demanded to know the findings
from the physician. The physician went ahead and told him the news and he felt that surgery
would send him to an early grave. He felt uncomfortable and confused with all the information
regarding the surgical procedure and everything that needed to be done.
His sons were also called to the hospital and given the news. They were informed of the entire
requirements for the procedure to be carried out. They enquired on the cost required for the
whole procedure which the doctor gave them. The cost was high for them since they had no
health insurance and did not qualify for Medicaid. Looking at the condition Mr. Robert was in
the physician explained to them that an urgent action was required which they agreed. The
physician also enquired on the health history of the patient which they highlighted that he had
a healthy life except for the case that he was becoming forgetful in many things and had few
falls in the last three months. They also had questions for the physician regarding the possibility
of walking normally again after the surgery which he assured them that the chance was higher.
They were later presented with an Informed Consent Form and requested to consent for him
since he wasn’t in a position to do it which they did. The surgery was scheduled for the next day
at 0300hrs.
During that evening after being served a meal, Mr. Robert complained that he needed only
liquids since his tongue pained and couldn’t chew. The nurse in the shift never paid much
attention to know more about the tongue but gave in to his demands. He was also assisted in
carrying out activities of daily living. The next day he underwent blood and urine analysis and x-
ray on both knees prior the surgery. Later he was given general anesthesia by injection and
inhalation and the surgery was successful. At the postoperative recovery area the patient was
closely monitored and it was observed that he never ate well. On assessing his complaints
about the tongue the doctor found a lump on the side. He was diagnosed with oral tongue
cancer. He underwent another surgery to remove the tumor. After regular checkups the doctor
noted that it was advancing towards the back of the tongue and chemotherapy, drugs and
radiation were carried out. The cost was too much to bear already for the family. Mr. Robert
felt that he was a burden already despite being in pain. The doctor continuously sedated him to

relieve pain. Either he proposed to his sons and the physicians that he had lived his life and
needed to rest since all he encountered at that moment was pain and suffering and burden to
the family which to him wasn’t called for.
Question Two
When it comes to ethical thinking and decision-making, moral issues greet health professionals
each day bombarding them with questions on how to approach certain issues concerning their
clients and the general healthcare system (Burkhardt & Nathaniel, 2013). Questions on the right
of the patient, fairness to the diverse patients, morality in view of medical technology and
justice are perplexing to the health professionals when it comes to ethical decision making
(Burkhardt & Nathaniel, 2013). In dealing with ethical issues there is a need to first think
through the issue, ask questions regarding the issue and finally draw on factors to consider
(Chadwick & Gallagher, 2016). In resolving the problem, the first step is analyzing the moral
issue (Burkhardt & Nathaniel, 2013). Getting the facts in this case is that Mr. Robert is in great
pain and overwhelmed by the whole process of continuously seeking medical attention. He is
also worried about the cost burden to his children. He further says that his age was reckoning
enough to warrant him an end of life. The doctor is aware that the cancer treatment is
fastening the death of his client despite the client requesting for a mercy –killing.
To be able to deal with the above issues it is important to determine which actions will be
morally best for the case. It will be best to consider utilitarian approach which suggests that
ethical actions are those that provide the greatest balance of good over evil. The approach
seeks first to identify which courses of action are available to the case. The available actions for
the physician are on continuing to administer terminal sedatives to the patients to relieve pain
together with chemotherapy to prevent the advance of cancer. The patient is also opting for
euthanasia to stop the pain and suffering on him and relieves the cost burden to the family. To
the sons they are left in dilemma on which side to choose, whether to support the doctor to
continue with medication as they incur more cost or be in support of their father to end his life.
The doctor is also faced by the challenge of whether to follow the patient’s autonomy and
assist him to a quick death or ignore the patient’s demands. To resolve the actions we have to
consider who will be affected by each action and what benefits or harm will be encountered in
each action (Burkhardt & Nathaniel, 2013). Mr. Robert is in pain and has a terminal illness and
his option is euthanasia. According to utilitarianism on mercy killing is that the right thing to do
is that which results to greatest amount of happiness to the greatest number of people
involved (Stylianidou, 2013) (Chambers, 2011). Considering this the patient will be relieved

from pain and suffering. His sons will also be relieved from cost expenses and will not continue
seeing their father suffer. It is also said that any human being who is pitiful cannot allow
another living thing to suffer for a no good end. The dilemma on the sons is whether to have
pity on their father while he is suffering with no hope of survival or give him the dignity to die
peacefully (Sharp, 2012). This is voluntary euthanasia since the patient has requested the end
of their life early due to terminal illness that is causing an immense pain with no hope of
survival. Death cannot be avoided and suffering is in vain (Sharp, 2012). If they are in support
of it the physician will assist in suicide by increasing the dosage to hasten death. Logically the
patient needs to be relieved from suffering.
But is it morally right or wrong? More important we say that it is not okay to kill another human
except for the cases of retributivism (Sharp, 2012). According to Kantian, mercy killing will
break the seal of killing and result to all forms of killing that is acceptable. This will make people
kill without value for life (Friend, 2011). Kantian is contradicting since they accept the
retributivism form of killing while in denial of mercy killing (Paterson, 2017). This is because
they are all fundamental killing (Paterson, 2017). Either life has exceptions or on this case we
cannot consider mercy killing because of hardships of life like poverty. But we can focus on the
unbearable pain and suffering that will result in no other way but death (Paterson, 2017). For
the patient death is better since he will surely die, he is suffering, no person’s rights being
violated and death will only benefit him in pain and will take nothing away from others
(Chambers, 2011) (Vaughn, 2015). Either by embracing the phrase “the right to death with
dignity” because of pain and suffering due to terminal illnesses will make more people disposed
from our communities believed to be civilized. Especially older adults prone to these illnesses
will be extinct. Hence it is the duty of the physician to provide care and protect life and not to
harm patients. Allowing euthanasia will lead to critical decline in care quality of the patients
with terminal illnesses. Palliative care can be provided to the patient for relief from suffering
and pain, support the patient and the caregiver. The care is an active, compassionate and
creative care towards the dying (Ten Have & Welie, 2014).
Question Three
When it comes to health profession there are character traits that enable us to be who we are
and act in ways that develop our greatest potential. These ethical virtues we strive on enable
full development of our humanity (Mitchell & Golden, 2012). Reflecting on them helps in
discovering what kind of people we shall be (Cannaerts, Gastmans & Casterlé, 2014). These
virtues are courage, fairness, generosity, honesty, compassion, integrity, prudence, self-control
and fidelity (Chadwick & Gallagher, 2016). These virtues form habit. They become part of us
and once faced with ethical questions we are bound to naturally act in consistent with them.

They are meant in identifying the most important ethical considerations and not provide
automatic solution to problems (Chadwick & Gallagher, 2016).
Ethical principles are present in almost every aspect of daily life and healthcare practices
(Chadwick & Gallagher, 2016). In this case there is the principle of truthfulness (Hsu, 2011).
Truthfulness is about telling the truth to the client who has the right to know the truth. In the
case study, Mr. Robert demanded to know the truth regarding the physician’s findings of his
leg. The physician was open to him regarding the position of his knee and that the kneecap
needed to be removed. He also briefed him on the necessary measures to be undertaken to
ensure good care towards him and later consulted his sons since there was no confidentiality
brought about by the client. It involves being honest with the patients about conditions,
procedures, medications, and risks which are often unpleasant but necessary (Dossey &
Keegan, 2012). Either at times it may not wholly apply since the moral duty of the physician is
to do no harm. Either it should also be exercised with caution so that it is not abused (Hsu,
2011).
The principle of beneficence denotes on the provision of benefits and good to patients
(Kangasniemi, Pakkanen & Korhonen, 2015). It requires the health care professionals to weigh
risks and make decisions that are going to provide the maximum benefit to the patient (Hsu,
2011). In the case the physician observed that to enable the client lead a better life after the fall
the kneecap needed to be removed and also ease pain. Either the possibility was he would
require a stick for a stronger support. The patient was also diagnosed with cancer which
required a series of chemotherapy to prevent its further advancing to the throat which would
cause a sudden death.
Patients’ autonomy signifies that the health professionals have a duty to respect decision
making of the capabilities of the patients (Bjarnason & LaSala, 2011). In regard to this the
health professionals have to provide all the information regarding the available options to the
patients to enable them choose the best for them (Holmes, 2016). Regarding the kneecap
removal there was no other option available and besides the kneecap was badly damaged for
other options. The physician declared the truth to the patient and his family and they had to
ultimately bear the consequences. A patient has to be conscious in order to grasp the
understanding of the information provided and make relevant decisions (Judkins-Cohn, et al,
2014). The principle also requires complete information provided without hiding anything to
the patient to enable a holistic decision making (Sandman, et al, 2012) (Cannaerts, Gastmans &
Casterlé, 2014). This will enable self-confident and freedom to take life into their own hands
rather than the relatives. In this case the patient can opt not to undergo treatment and choose
to die with dignity without pain and suffering (Judkins-Cohn, et al, 2014). Human beings have a
right on deciding on what to do with their lives (Sandman, et al, 2012). In the case study the

patient had opted for mercy killing to end suffering and pain in his life. The principle of
beneficence supports the principle of autonomy with respect to the patient (Kangasniemi,
Pakkanen & Korhonen, 2015). Truth telling to the patient and leaving them to make their own
decisions is beneficial and makes them feel more confident with their life. If declaring the truth
to the patient could harm the patient the health professional can distort the patient’s
autonomy (Holmes, 2016). In the case, Mr. Robert was requesting for a mercy killing to ease
suffering to him and he felt that he was bound to die after all which is why he was choosing a
peaceful death rather than continue living in pain and anguish. In this case distorting the
patient’s autonomy would only be right if the patient was given full information regarding the
course of care that would be given to him in the meantime which is palliative care in order to
reduce pain and suffering while giving him a comfortable life in the remaining days of his life
(Kangasniemi, Pakkanen & Korhonen, 2015) (Holmes, 2016) (Materstvedt, 2013).
Conclusion
It is the work of the health care professionals to tell the truth to the patients. The patients have
a right to acquire the correct information regarding their illnesses and the crucial processes
required to undertake in order to gain full recovery. Patient’s autonomy may be respected but
can be of benefit or detrimental to the patient. When it comes to mercy killing, right to life is a
reality and succeeds the right to death with dignity. Hence palliative care provides the dignity of
death.

References
Bjarnason, D., & LaSala, C. A. (2011). Moral leadership in nursing. Journal of Radiology
Nursing, 30(1), 18-24.
Burkhardt, M. A., & Nathaniel, A. (2013). Ethics and issues in contemporary nursing. Nelson Ed
Cannaerts, N., Gastmans, C., & Casterlé, B. D. D. (2014). Contribution of ethics education to the
ethical competence of nursing students: Educators’ and students’ perceptions. Nursing
ethics, 21(8), 861-878.
Chadwick, R., & Gallagher, A. (2016). Ethics and nursing practice. Macmillan International
Higher Education.ucation.
Chambers, S. (2011). The illusion of the “slippery slope”: How religion and culture shape
Canadian doctors’ attitudes toward euthanasia and physician-assisted suicide.
Dossey, B. M., & Keegan, L. (2012). Holistic nursing. Jones & Bartlett Publishers.
Friend, M. L. (2011). Physician-Assisted Suicide: Death With Dignity?. Journal of Nursing
Law, 14(3-4), 110-116.
Holmes, D. (2016). Critical interventions in the ethics of healthcare: Challenging the principle of
autonomy in bioethics. Routledge.
Hsu, L. L. (2011). Blended learning in ethics education: A survey of nursing students. Nursing
ethics, 18(3), 418-430.
Jones, D. A. (2011). Is there a logical slippery slope from voluntary to nonvoluntary
euthanasia?. Kennedy Institute of Ethics Journal, 21(4), 379-404.
Judkins-Cohn, T. M., Kielwasser-Withrow, K., Owen, M., & Ward, J. (2014). Ethical principles of
informed consent: Exploring nurses’ dual role of care provider and researcher. The Journal of
Continuing Education in Nursing.
Kangasniemi, M., Pakkanen, P., & Korhonen, A. (2015). Professional ethics in nursing: an
integrative review. Journal of advanced nursing, 71(8), 1744-1757.
Materstvedt, L. J. (2013). Palliative care ethics: the problems of combining palliation and
assisted dying. Progress in Palliative Care, 21(3), 158-164.
Mitchell, P., & Golden, R. (2012). Core principles & values of effective team-based health care.
National Academy of Sciences.

Paterson, C. (2017). Assisted suicide and euthanasia: a natural law ethics approach. Routledge.
Sandman, L., Granger, B. B., Ekman, I., & Munthe, C. (2012). Adherence, shared decision-making
and patient autonomy. Medicine, Health Care and Philosophy, 15(2), 115-127.
Sharp, R. (2012). The Dangers of Euthanasia and Dementia: How Kantian Thinking Might Be
Used to Support Non Voluntary Euthanasia in Cases of Extreme Dementia.‐ Bioethics, 26(5), 231-
235.
Stylianidou, S. (2013). Terminal cancer patients and euthanasia—the church’s position. Hellenic
Journal of Surgery, 85(2), 105-108.
Ten Have, H., & Welie, J. V. (2014). Palliative sedation versus euthanasia: an ethical
assessment. Journal of pain and symptom management, 47(1), 123-136.
Vaughn, L. (2015). Doing ethics: Moral reasoning and contemporary issues. WW Norton &
Company.