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Ethical Decision-Making Framework
Identify issues and collect information
Jenny Kim, Jenny Kim’s 15 years old Daughter Jillian, Dr Franks, RN Huang, Jenny’s Husband Anthony
1.2 Identifying the issues:
Did the action of the Doctor and nurse of blood transfusion for Jenny was unethical and negligent?
What Dr Frank could do when Anthony denied blood transfusion for his wife and daughter?
Will it be ethically or legally correct for RN Huang to share or discuss information with Anthony’s sister against Anthony’s wish?
Evaluate the issue
(a) ICN Code of Ethics
Element 1 of the ICN Code of Ethics (2012) will be applied in this case scenario that states ‘the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected’. Therefore, RN Huang and Dr Frank are required to make the decisions, which respect the cultural, customs and spiritual belief of family and individual and must not conduct blood transfusion against their will to avoid ethical and legal consequences. This element also informs that nurses focus on providing the culturally appropriate information to receive consent for care and related treatment. In the case of Krigger v Williams  HCA 65, the court had determined the right of religious freedom, according to which Anthony has the right to decide for his family, who are not in a condition to provide their consent. Therefore, the denial of Anthony to provide consent for blood transfusion must be respected. The nurse is also required to have a judgement in sharing personal information, according to which Huang must not share the personal information of Jenny and Jillian with Anthony’s sister.
(b) Ethical principles
Autonomy: According to the ethical principle of autonomy, Jenny has the right to receive the treatment according to her religious and cultural choices. Jenny also had advanced health directives and ‘No Blood’ on her card according to her religious identity. Therefore, her choice should be respected. Autonomy is also associated with self-determination, which requires health professionals to conduct any treatment that is against the wish of the patient and their family.
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Beneficence: It was the best interest of Jenny to seek the consent for her blood transfusion from her husband when the RN Huang and Dr Frank came to know about her being a Jehovah’s Witness’. When her husband had not provided the consent for the blood transfusion to his wife and daughter, it is in the best interest, as the family member has the right to make a decision, when the patient is not in a condition to provide their consent. Competent adult patients could not be treated against their will and if they have their health directives, then the benefit of the patient must be identified in their choice.
Non-maleficence: Jenny had been religiously harmed by the blood transfusion and Jillian is also harmed by Anthony’s decision to reject blood transfusion for her. The confidentiality of the patient’s information can also be harmed if RN Huang shares their health information with Anthon’s sister against the will of Anthony.
Justice: Justice is to provide fair and equitable treatment to a patient when required. However, blood transfusion is refused by Jehovah’s Witnesses. Therefore the justice and principle of beneficence must prevail and health professionals must use alternative measures for the treatment of the patients.
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(C) Law/Legal issues
The legal problem that can arise in the case is that the blood transfusion was conducted on Jenny, as Dr Frank had no idea about her being a Jehovah’s Witnesses. However, when RN Huang checked Jenny’s purse and came to know that she has a ‘no blood’ card and valid advance health directive (AHD) that stated the same, she immediately informed the doctor. Health professionals can be considered legally liable for going against the wish of the patient. However, Section 16 of Part 5 (Voluntary aid in an emergency) under the Law Reform Act 1995 (Qld) states that ‘medical practitioner, nurse or other person prescribed under regulation in respect of an act done or omitted in the course of rendering medical care, aid or assistance to an injured person in circumstances of emergency’. According to this provision, Dr Frank and RN Huang will not be considered as liable for conducting blood transfusion during providing medical care.
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3.1 Code of Conduct for Nurses
Principle 2.2 regarding decision making states that decision making about the healthcare of the individuals is the shared responsibility of the person (including the nominated partner, family or friend), the nurse and the health professionals. Therefore, Anthony being a shared decision-maker must be involved in decision making regarding blood transfusion as it is required to support the decisionmaker ‘supporting the person in a manner consistent with that person’s values and preferences’. In the case of Adelaide Co of Jehovah’s Witnesses Inc v Commonwealth  HCA 12, it was determined that an individual could not be prohibited from the practice of religion. This principle also informs that health professionals must recognise the substitute decision-maker, which is Anthony for Jenny and Jillian, therefore, is a legal guardian for Jillian and legal decision-maker for Jenny, the decision of Anthony must be respected.
3.2 Options for Actions
The immediate step that could be undertaken is that professionals can take the support of other health professionals, as the Principle 2.2 states that professionals must recognise their scope of practice and must seek the support o other health professionals for the best interest of the patients. Principle 2.3 of the NMBA Code of Conduct informs that professional must act according to the person’s capacity and consent. Principle 3.2 states that culturally safe and respectful care must be delivered. This principle also informs that professionals are required to understand that ‘only the person and/or their family can determine whether or not care is culturally safe and respectful’. Therefore, the cultural and religious safety should be maintained by the health professionals and alternative treatment to blood transfusion can be applied (Cho & Jeyarajah, 2019). The alternative treatment may include the Blood Substitute and Erythropoietin Therapy or pharmacological management of patient’s condition (Hoffman, 2016).
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Another Principle for the Code of Conduct for nurses (2018) applicable in the case is code 3.5 about confidentiality and privacy. According to this code, nurses have the legal and ethical responsibility of protecting the privacy and maintaining the confidentiality of personal information of the patients. This code also informs that people have the right to hold confidence in nurses and health professionals that they will hold information of the patient in confidence unless the disclosure of the information is required by the law. Principle 3.5 (a) states that ‘respect the confidentiality and privacy of people by seeking informed consent before disclosing information, including formally documenting such consent where possible’. Therefore, RN Huang must not share the personal information about the patients with Anthony’s sister against his wish to maintain the ethical and legal responsibility of maintaining the confidentiality of information.
Principle 3.6 of the NMBA code of conduct informs about the end of life care, According to Principle 3.6 (b), health professionals must understand that patient has the right to refuse or withdraw from treatment. Since Jenny had the no blood card and also valid AHD to refuse to blood transfusion, therefore, professionals must respect her right. Principle 3.6 (c) also informs that professionals must also respect the diverse cultural practices and beliefs related to death and dying. Therefore, professionals must respect the rights of Jenny and her family to decide critical conditions and professionals must focus on relieving problems as much as possible through alternative treatments.
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The first step to be implemented is to communicate the problem effectively to Anthony and making him understand the significance of blood transfusion. In doing so other experienced and qualified senior health professionals can be involved. The senior professionals can also discuss the issue with Anthony and can ask him to provide his consent.
As Anthony is not ready to provide his consent for blood transfusion for his wife and daughter, professionals can discuss the range of alternative treatment options with Anthony for protecting the life of patients. Health professionals have the duty of care and responsibility for delivering beneficial and justified care. Therefore, the professionals are required to immediately apply the alternative treatment to save the life of Jenny and Jillian. Professionals have the duty and responsibility of shared decision making, therefore, they must involve Anthony in discussing alternative treatments to avoid legal and ethical issues.
Dr Frank and RN Huang have the duty of respecting patient and their family’s right and must be treated in a manner that is culturally safe and respectful. Confidentiality of information must be maintained by an RN to ensure ethical practice.
At the time of the ethical issue, nursing professionals can seek support from senior professionals and ask for their guidance. The ethical practice must also be based on evidence-based knowledge, cultural awareness and cultural sensitivity. The rights of the patient and family must be protected to prevent ethical dilemmas. In the case-patient is Jehovah’s Witnesses, therefore, blood transfusion is not religious and culturally acceptable for them. The refusal to blood transfusion by patient and family must be respected. The health professionals, including doctor and nurse, must focus on providing alternative treatment therapies to ensure care delivered is culturally safe.
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Adelaide Co of Jehovah’s Witnesses Inc v Commonwealth 1943 HCA 12
Cho, E. E., & Jeyarajah, D. R. (2019). Ethics of Surgical Intervention in Jehovah’s Witness Patients. In Surgical Ethics(pp. 283-293). Springer, Cham.
Hoffman, A. (2016). Jehovah’s Witness parents’ refusal of blood transfusions: Ethical considerations for psychologists. Journal of health psychology, 21(8), 1556-1565.
International Council of Nurses. (2012). THE ICN CODE OF ETHICS FOR NURSES. Retrieved from: http://www.aynla.org/2012/12/icn-code-of-ethics-for-nurses-2012/
Krygger v Williams 1912 HCA 65
NMBA. (2018). Code of Conduct for Nurses. Retrieved from: http://www.nursingmidwiferyboard.gov.au/documents/default.aspx?record=WD17%2F23850&dbid=AP&chksum=L8j874hp3DTlC1Sj4klHag%3D%3D
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