Ethical Decision Making
Joan, a thirty-nine-year-old mother of three young children, has been coming to Nina for therapy for the past year. She was involved in a motor vehicle accident and sustained multiple injuries including bilateral fractured femurs, a crushed calcaneus, an L2 fracture and deep dermal wounds to the trunk that required skin grafting. She enjoys coming to therapy and has been steadily reaching her goals. She is now able to ambulate independently. Joan's therapy has included scar management including scar mobilisation.During the 12 months of therapy, Joan and Nina have had a number of friendly conversations. Nina has learned that Joan is very concerned about body image, She is worried about the scarring and she also shared that she worked very hard to get her figure back after the birth of her children. She has mentioned that she admires her mother and her sister who both managed to sustain an upbeat attitude despite being "disfigured by mastectomies".
Recently during treatment, Nina discovers a small lump in Joan's right breast. She gently informs Joan and suggests she make an appointment with her doctor right away. Nina could sense that Joan was blocking out what she had to say. A month has passed since the discovery of the lump. Today in therapy Joan admits that she has not yet gone to see a doctor and doesn't want to discuss it. Nina is concerned that Joan is not facing up to the realities of the situation and is not making sound choices about her health.
Ethical Decision Making - Joan and Nina
1. Identify the problem*
*Be careful not to "hide" behind the law or regulation. The first step is to recognize this as a moral problem. Yes the law and the standards of practice say that we must protect patient confidentiality. These rules will contribute to our decision-making but should not solely determine our actions. Can you think of why not? (What was the spirit or intent of the law? We have other obligations to our patients i.e, to act in their best interests. When rules and laws compel us to harm others, they made need to be broken or reinterpreted in context.)Ethical Conflict
Nina has a relationship of trust with Joan. Joan confides in Nina knowing that the information will be held in confidence. If this trust is broken, Joan may not feel she can be candid with Nina, may withdraw from treatment and may generally become suspicious of health professionals. Joan should be allowed to make her own choices without interference from others and should be supported in her decision-making.Nina has a duty to act in her patient's best interests. She knows that she should not normally break her duty of confidentiality but the consequences of that action are grave - Joan's life is in danger. While Joan is cognitively competent, she does not seem emotionally able to independently face up to the fact that she may have a tumour that requires treatment. Nina feels she has a duty to tell someone about the lump so that Joan receives early treatment that could save her life.
2. Whose problem is it?
- Nina needs to take action
- Joan will be affected
3. What are the facts?
- There is a history of breast cancer in Joan's family
- Joan has a concern about body image
- Joan is in the midst of a lengthy rehab process.
- Joan seems to be "in denial" (value judgement?)
- Joan has young children
- Early treatment is lifesaving
- Joan has known about the lump for a month without taking action
- Breaching confidentiality may be considered professional misconduct
- It is not normally considered a breach of confidentiality to share medical information between members of a health care team
4. What duties are involved?
(See number 1)5. What are the alternatives?
- Maintain confidentiality.
- Nina avoids getting into trouble. Respects confidentiality.
- Time is not on Joan's side
- Contact a third party
- Will have violated Joan's trust. Joan can still refuse to be seen by the doctor.
- If family is informed, violates Joan's trust but also a societal expectation. Erodes the relationship for everyone.
- Continue to maintain confidentiality, but use all of your powers of persuasion to convince Joan to act.
- This may or may not include advising Joan that you wish to inform her doctor.
- e.g. Give her the contact numbers of any agency or group that can advise or support her.
- Supply her with all the factual information you know or can get your hands on.
- Push her along by calling the doctor for her and handing her the phone.
- This options maintains confidentiality thus giving Joan power over her own decisions while works towards acting in the patients best interests and protecting her from harm.
