Ethical Decision-Making in Nursing: Mrs. Pearl's Pacemaker Case Study

This case study delves into a complex ethical dilemma in nursing, centered around Mrs. Pearl, a patient whose daughter, holding power of attorney, objects to a pacemaker. The assignment applies the ethical decision-making model, identifying the ethical problem, collecting information, developing and analyzing alternative solutions, selecting the best course of action, and creating implementation strategies. The core ethical principles of nursing—autonomy, beneficence, non-maleficence, justice, fidelity, and veracity—are examined in the context of the case. The study presents three alternatives: respecting the daughter's wishes, convincing the daughter of the treatment's necessity, and overriding the daughter's objection. The chosen solution involves educating the daughter about the patient's condition and the importance of the treatment. Legal considerations, professional standards, and the nurse's gut feeling are used to justify the decision, emphasizing the need for informed consent and adherence to ethical and legal requirements. The case highlights the importance of balancing patient autonomy with the duty to provide beneficial care.

The Ethical Principles of Nursing and Application
Step 3: To develop alternatives to solutions, analyze and compare (Park, 2011)
When most individuals believe about ethics or morals, they believe about rules
to distinguish between right and wrong, rules about good and prudent. Ethics
and morality help nurses to think and to discover a response when they ask
themselves: "What are they supposed to do? How do you comply in the face
of certain conditions?" It can be a challenge to determine the right course in
the face of a challenging ethical dilemma (Park, 2011).
In a perfect world, legislation at all levels and all appropriate codes of ethics
would harmonize fully, but not always. Nurses are unable to answer all
circumstances a nurse has to face using all the ethical codes and rules
(Kennelly, 2011). There may be times when nurses have to exert their private
and professional judgement because they are not in accordance with legal or
professional requirements and the legal and professional requirements may be
inconsistent. The nurse sometimes has to choose options which are legal but
not ethical for her survival (Stinson, 2016).
The principles of ethical nursing follow all six: autonomy, beneficence, non-
maleficence, justice, fidelity and veracity (Parks, 2011). The principle of
autonomy is that every client has the right to decide what and how to look
after him or her (Coggon and Miola, 2011). Beneficence is the principle of
taking every step towards enhancing the client’s life. A holistic approach,
including all factors in the life of the client, makes this possible
(Plato.stanford.edu, 2009).

The principle that no harm is done is non-maleficence. Ethically, this requires
the nurses to prevent harm to be caused to the clients, from their own hands or
another. (Accesspharmacy.mhmedical.com, 2019). The principle of justice is
that all individuals are treated equally. Fidelity is the concept of fulfilling one's
own and other obligations and promises (Haddad 2019). The concept of
veracity is that the nurse always has to say the truth. It also gives the client the
right to know everything about his / her health and care (Fowler and Davis,
2013). These ethical principles form a solid basis for nurses. Apart from these
six traits confidentiality is another ethical value which plays an important role
in nursing practice. This is the most important principles that should be
considered in nursing profession respecting the patient/client and preserving
human dignity, altruism and sympathy, maintaining patient's privacy and
commitment to confidentiality and trust (Zahedi et. al, 2013). The following
ethical theories are equally applicable for this case study
a. Utilitarianism is a normative ethical concept which takes the moral correct
course, and which provides the highest balance of benefits over harms.
b. Duty based ethics. The principles of actions without respect to implications
of adherence to guidelines, should be based on moral standards describing
correct behaviour.
c. Virtue Ethics is a broad term for theories, which emphasizes in moral
philosophy, the function of personality and virtue instead of doing one's
obligation or acting to produce excellent results.

d. The application of an ethic of nursing care enhances the ability of nurses to
address their patients ' requirements in ways that are based on each patient's
specific welfare and condition.
Apart from these ethics, the conscience of the health professional or her
religion also play significant part in making health decisions. Moreover the
nursing decision making is also influenced by the rules and guidelines issued
by the institute where the nurse is working.
The Latin term "nutritious" is used as "nurse," which implies to nourish. It is
definitely the task of a nurse to nourish, promote health and growth (Adams,
2016). If a nurse complies with the six values, she is better equipped to
nourish. A nurse must not only look at the ethical consequences during
consideration of actions, but also the legal consequences. The principles of
law and ethics are in place for people to live together in peace. Many laws
stem from ethical principles, and they become laws because of their assistance
from the majority of the population.
To become a law, an ethical principle must be applied by law enforcement
authorities and be applied equally to the whole population. This is not
applicable for all ethical principles but they are equally significant in
encouraging peaceful interactions and survival of species. Although the
governments do not apply ethical principles, they do exist through licensing
boards. Nurses and others who often ignore ethical practices risk their licenses
being revoked.
In the case study, the daughter of Mrs Pearl who is having the power of
attorney is the decision making authority. Though the condition of Mrs Pearl

warrants a pacemaker for supporting, however, her daughter is against that.
This would be an ethical dilemma because it would challenge nearly all the
ethical principles of nursing: autonomy, beneficence, non-maleficence, and
veracity. Autonomy, because the client is refusing treatment. Beneficence and
non-maleficence, because if the nurse accepts the request of the client she
knows it will cause harm. Veracity, because the nurse knows if the treatment
is denied it would be harmful and she is obligated to tell the client the truth. So
there are three alternatives (Park, 2011).
Alternative 1: As per the daughter, pacemaker would not be inserted inside
Mrs Pearl body as she is very old and may not be able to support any
additional gadget. The negative impact of this alternative is that Mrs Pearl
blood pressure is very low, the heart has become very weak and keeping a
patient without proper treatment in a hospital setup is unethical and illegal.
Alternative 2: Convince the daughter of Mrs Pearl about the importance of the
treatment and get her concurrence for this treatment. This option supports all
six principles of nursing.
Alternative 3: Overrule the objection raised by the daughter and the hospital
should go by the prescribed treatment. However, this is against the autonomy
of the client however other principles of nursing like beneficence, non-
maleficence, justice, fidelity and veracity are supported.
Step 4: Selection of the best alternative and justification (Park, 2011)
The best solution to this dilemma would be to acknowledge the client’s
request and very respectfully educate her on why that treatment is necessary at
that point of time as they are duty-bound to make their best efforts to save the

patient. The hospital is having some obligation and duty when a patient is
admitted. The fact is that the patient has been admitted to hospital for
treatment and treatment cannot be denied. The client will realize the situation
and may agree for acceptance of the treatment to be given to her mother. So
the best alternative is alternative two. The hospital should go ahead with the
treatment after convincing the daughter of Mrs Pearl. Before fitting the
pacemaker, the hospital authorities have to comply with all legal formalities
with the daughter of Mrs Pearl. The chosen alternative should be implemented
after the following points were given due considerations:
1) “Legal test. Is the chosen option consistent with the law?” Yes
2) “Front-page test. What if this case were published in one of the popular
newspapers?” Yes
3) “Gut-feeling test. Is your decision consistent with your gut-feeling as a
nurse?” Yes
4) “Role model test. Is an RN you respect likely to make the same decision?”
Yes
5) “Professional standard test. Is your decision acceptable to the nursing
profession?” Yes
Step 5: Develop strategies to successfully implement the chosen alternative
and take action (Park, 2011).
The nurse has to tell frankly the daughter of Mrs Pearl about the importance of
installing the pacemaker as the condition of the patient is very serious and they
cannot keep the patient without any treatment. Moreover, the pacemaker will

improve the heartbeat of the patient and the condition will stabilize. Even then
if she is adamant, the hospital should try to contact other close relatives or
friends of the patient who can convince the daughter. But the ultimate aim of
the hospital is to continue with the treatment as per norms. One of the key
problems in medical therapy is the component of approval. The patient has the
right to self-determination and independence. She may refuse therapy unless
she has the doctor's permission for therapy in an emergency. The acquired
approval should be legal. Under criminal law and tort, a doctor who treats
without valid permission is responsible. The law presumes that the doctor is in
a dominant position. Therefore, after supplying the required data, approval
should be reached.
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