For many years, physicians and nurses have engaged in intense discourse on issues relating to truth-telling and deception. Telling the truth has in many occasions been regarded as the preferable option that is essential to human relationship. On the contrary, deception has been viewed as a choice that, at least, requires justification. A challenging ethical dilemma faced by many healthcare providers, especially those working in the department of oncology, is whether to reveal the truth about the diagnosis to a terminally ill cancer patient. Deception and truth-telling are approached in different ways based on a culture and country in question. Studies have revealed that healthcare professionals should always tell the truth to their patients regardless of their conditions. In developed nations, revealing the truth to a patient is considered as beneficial. In developing countries, such choices are significantly influenced by culture. In nursing, the code of ethics provides a wide range of principles of nursing and establishes duties and responsibilities of nurses. In their line of duty, nurses should recognize that their decisions are not made in isolation, but occur within a context of care that encompasses such levels of relationship as individual, societal, familial, and organization ones. The paper is aimed at exemplifying an ethical issue in healthcare, as well as nursing principles and values that may inform a decision to develop a solution to an otherwise insoluble problem.
Truth-Telling versus Deception
Consideration of truth-telling is usually based on effects that deception may have on the quality of life of a patient. Good rapport and relationship between a patient and a healthcare professional are based on trust that is created in the delivery of care. Trust can only be created in an environment where truth communication is upheld. Many healthcare professionals consider telling the truth as an ethical issue over and above a moral obligation. In this respect, patients expect that physicians and nurses will remain honest and will always tell the truth just as health professionals demand the same from patients. Research has revealed that truth-telling in a healthcare setting is not only a pivotal element of respect owed to patients, but it also promotes trust. Disclosure of truth can be an integral ingredient in creating a continuous carer-patient bond.
Nonetheless, truth-telling may turn out to be an intricate business, especially in a situation when total openness may result in more harm than good. All information that has the potential to negatively impact the view of the patient can only serve to increase uncertainty and, as such, non-disclosure is the best choice. When dealing with a normal medical situation, truth-telling serves to inform patients about their health condition so that they may actively participate in the treatment process. Information given by healthcare providers not only affects reaction of the patient, but also that of close family members. Whenever possible, it is good to involve patients in their care so that their response to palliative and therapeutic care is appropriate. As aforementioned, deception can heighten doubt and create indecision, all of which affect psychological disposition of the patient.
Similarly, truth-telling has the potential of crushing hopes and dreams of a patient. For terminally ill cancer patients, hope is a vital mechanism for dealing with cancer and this can be shattered by too much detail. Disclosing the truth to a terminally ill patient can only be interpreted as a death sentence by the ailing individual and their close family members. Therefore, this means that disclosure in this case would cause misery, harm, and disillusionment, all of which may affect the quality of life of the patient.
Justification for Non-Disclosure
In some instances, not disclosing the truth on prognosis and diagnosis can be justified, especially in Third World countries where healthcare is still underdeveloped. In countries like the United States, Britain, and Canada where healthcare facilities are advanced, terminally ill patients can be encouraged and comforted that all possible medical options shall be exhausted, so that they can depart with no pain and with dignity. In underdeveloped states where the quality of healthcare is still poor and palliative care services are missing, terminally ill patients have to come upon the vision of dying in pain and distress. In such case, non-disclosure can be justified since truth-telling would only serve to exacerbate the already miserable situation.
In developed nations, healthcare professionals delegate a substantial degree of personal responsibility and duty to patients. In such an environment, patients are expected to make decisions based on choices given by healthcare providers. Patients make a choice on direction and treatment process they prefer from available options and participation of healthcare providers in decision-making is significantly curtailed. In situations where non-disclosure promises to improve the quality of life of the patient, deception is justified.
There is strong evidence indicating that most patients are loath to know or ask for information regarding their diagnosis or even prognosis. In a circumstance when patient’s close relatives are resolute on concealing such information, nurses should listen to their wishes, but they should also explain the need of disclosing all relevant health data and conditions to the patient. In many cases, patients are in a position to guess their current health status from the diagnosis and, when contradictory information is given, this may result in the loss of trust and confidence between the patient and healthcare providers. This may not augur well for the delivery of health services, as well as contravening fundamental nursing principles.
Guiding Nursing Principles in Addressing Healthcare Dilemmas
Ethical principles can play a huge role in informing decisions and guiding practice in the healthcare delivery. Though the way these values are interpreted depends on circumstances, setting, and complexity of the ethical conundrum, they can help solve ethical dilemmas. These principles help in decision-making relating to ethical actions in a particular situation. These principles include principles of ethics, fairness, beneficence, autonomy, and distributive justice.
The autonomy principle defines the right of patients to choose what they believe is best for their health. It is underpinned on the need for patient inclusion in decision-making regarding their healthcare program. This principle emphasizes the need of respecting the patient’s will and choices in treatment and the importance of making well-versed choices about matters relating to life, health, and death. A patient has the right to refuse treatment, as well as the right to confidentiality and full disclosure of information. Provision of terminally ill patients with honest and candid information is important as it helps them make right choices on how to manage and face their condition.
The principle of beneficence outlines the duty to help others, promote welfare of patients, and follow a desire to treat patients appropriately. The principle is pegged on the concept that this duty should override other obligations when delivering healthcare. When the principle of beneficence is applied without making reference to the principle of autonomy, it yields paternalism more often than not. Paternalism refers to an action that may be well-intended, but that negates some fundamental rights of the patient. When a cancer patient is terminally ill, a health professional has a duty to inform and guide the patient so that they can have authority in terms of treatment procedures. This principle is reinforced by the principle of non-malfeasance, which states that healthcare providers should seek to protect others from harm. Though these two principles must be exercised in accordance with nursing codes of conduct, personal judgment on the decision that shall yield more benefits to the welfare of a patient is solely made upon the healthcare giver’s discretion. Therefore, if a nurse weighs available choices and comes to a conclusion that non-disclosure favors the condition of the patient because otherwise it may not only reduce the quality of life, but also cause unprecedented pain, then it is a justifiable decision.
Ethics entails doing what is most appropriate (good) and causing no harm. However, how a nurse defines what is ethical can differ from one nurse to another. Nursing principles are formulated to ensure parity and provide them with tools to guide the process of decision-making in different situations. Even so, it is worth noting that application of these principles is shaped by experience, values, and beliefs of a nurse. As a result, diverse choices can be made in a similar dilemma.
Care ethics strives to maintain a healthy relationship between healthcare providers and patients. Also referred to as the moral theory, this theory seeks to promote a healthy relationship in the healthcare setting. It entails creating an environment that supports delivery of services to address each patient’s needs. Non-disclosure can only serve as an apt choice in circumstances when full disclosure can derail the process of treatment and significantly affect the quality of life of the patient. In an ethical dilemma when close family members propose and support non-disclosure, it is the duty of a nurse to weigh the gravity of the situation and assess implications of such action. If a healthcare professional is in a position to indentify a possible reaction of a terminally ill patient to non-disclosure and establishes that welfare is to be promoted by such a choice, then withholding the truth is a justifiable action. Care ethics seeks to provide nurses with guidelines on the need to provide required support to patients even when such support is not welcomed.
The scope of ethics entails defending, recommending, and systematizing the model of acting right and wrong. In this regard, ethics critically mirrors aspects of morality. However, being ethical does not necessarily entail observing set procedures and principles of practice in a healthcare setting. Codes of conduct and nursing principles incorporate the concept of ethical standards that all healthcare specialists who offer their services within the medical framework should follow. Nevertheless, principles involving feelings sometimes deviate from ethical practices. Ethical principles of what is apt or inappropriate, good or bad should be adopted by all healthcare personnel such as physicians and nurses as the guiding tool, especially in circumstances that call for critical thinking and decision-making.
The burden of determining effects of a decision relating to disclosure and non-disclosure lies squarely on the shoulders of a nurse. The most fundamental thing is ensuring that consequences of every action promote well-being of a patient and aids in the delivery of professional services. When encountering a moral dilemma, a health professional should reflect over it thoroughly so that they can define which ethical values and nursing principles are in danger of compromise. Failure to tell the truth about diagnosis and prognosis has the potential of overriding the patient’s autonomy. Nonetheless, from an ethical perspective, averting actions that can bring misery to the patient is not only appropriate, but also may be deemed a good nursing practice.
There are many scientific theories that are used to base nursing practices and care in all healthcare settings. Deontology put forward by Immanuel Kant is one of such theories exemplifying the moral obligation of healthcare providers in a health care setting. It states that intention determines moral appropriateness of a particular action. In this respect, it should appear to everyone that the choice made among available options is the best and that it promotes well-being of the patient. All available options must be exhaustively examined to arrive at the right decision. In the dilemma involving a terminally ill patient with just a few days left, a nurse can opt to adhere to the advice of the family members and conceal the reality from the patient or decide to disclose the truth about the looming destiny and as such ignore the advice of the next of kin.
Based on the principle of autonomy, a competent individual has the freedom and right of determining and acting in regard to a self-chosen plan. Therefore, health professionals who display moral dignity have a capacity to decide their destiny; hence, they should be allowed to make their own choices, take actions, and make evaluations in a bid to make service delivery as smooth as possible. No limitations should be imposed, nor should health professionals interfere with the liberty of patients.
Furthermore, the principle of autonomy prima facie contradicts the principle of higher moral weight. This principle is based on the guise that in certain situations action that appears to yield more moral weight than its alternative should be given priority. For example, a patient with a terminal disease that causes immense pain and agony may willingly request assistance in ending life. When such an action is supported by close family members, the principle states that sanctity of life supersedes individual’s autonomy. In the case of a terminally ill patient on the verge of dying, the nurse should abide by the code of ethics and disclose the truth to the patient. It is stated succinctly in the code that nursing care should be geared towards achieving a comprehensive health requirement of the patient and family across the continuum of care. Nurses should always endeavor to safeguard and uphold rights, safety, and health of patients regardless of the circumstances. Even concerning a restriction to disclose the truth to a terminally ill patient about the eminent demise, a nurse should weigh the gravity of such action to ensure that the action taken does not affect mental disposition of the patient negatively. A nurse’s key responsibility is to be professional, stay true to the cause to safeguard life, promote health, and most importantly adhere to the Nursing Code of Ethics.
Given intrinsic indistinctness of ethical dilemmas, a restrained way of thinking is needed. There are numerous approaches that are geared towards trying to unravel a conundrum in a healthcare setting. One of the most effective manners of reasoning is based on the cognitive-development theory. This theory explains chronological transformation in the manner through which social arrangements are construed. Individual progress is assessed through a sequence of stages of moral standing. The basic level of moral reasoning is the pre-conventional stage. At this stage, ideas of rightness and wrongness of every decision are evaluated. The second stage is the conventional stage when adherence to family and cultural values is evaluated. The last stage is the post-conventional stage whereby health professionals are expected to develop their moral values and use their conscience to solve a problem. In solving ethical dilemmas, these three moral reasoning levels are evaluated to determine moral rightness of a decision. In a situation when a cancer patient is terminally ill and family members opt for non-disclosure, a health professional must incorporate this proposition in deciding whether to inform the patient of the medical condition or not.
The above principles help in decision-making relating to ethical actions bound to be taken in particular situations. There are numerous approaches that are geared towards solving ethical dilemmas in healthcare settings. Though no single solution has been agreed upon by scholars, the nursing code of conduct, as well as nursing principles and practices should act as a guide in finding solutions to healthcare problems. One of the most exigent ethical dilemmas facing many healthcare givers, especially those rendering services in the unit of oncology, is whether to reveal the truth about a diagnosis to a terminally ill cancer patient. Truth-telling and deception are decisions that a nurse must make, but their consequences may derail or promote healthcare delivery. The common practice in the field of nursing is to give full information to patients, so that they can make choices on the treatment plan that they feel meets their needs. Nursing principles including the principles of autonomy, beneficence, care ethics, and nonmaleficence, which offer a valuable insight into how nurses should approach different ethical issues. In a normal medical setting, truth-telling serves to inform patients about their health condition so that they may actively participate in the treatment process. Information given by healthcare providers not only affects the reaction of patients, but also that of close family members. However, when facing an ethical dilemma on whether to disclose full information about diagnosis and prognosis to a terminally ill cancer patient, a nurse should approach the situation with utmost caution and care. This is because a wrong decision may totally crush hope and willpower of the patient. Therefore, nurses should ensure that they guide their patients through the management program and integrate their views in the care plan. It is also vital that family members and other relevant stakeholders are included in the process of solving the ethical dilemma.