The interplay between the law and ethical code is a crucial aspect in advanced practice nursing. While ethical principles are integrated into the legal system, this article seeks to explore the differences between legal and ethical reasoning. To achieve this objective, case law and analysis will be employed to provide a comprehensive discourse on legal interpretation, coherence, and logic.
This article discusses the importance of ethical reasoning in understanding ethics and law for nurses. It explains the role, issue, and rationale behind ethical reasoning and explores its components, benefits, and drawbacks. By comprehending these essential characteristics, nurses can make decisions that align with the nursing ethical code and legal regulations.
Case Study
An adult male patient, aged 40, is attending a dermatology clinic for a follow-up consultation concerning his delusions of parasitosis (DP). Despite undergoing multiple biopsies and laboratory tests, no evidence of parasitic infestation or any other underlying illness has been discovered. The patient’s symptoms have varied over time, with periods of improvement and worsening, but he is currently experiencing a flare-up.
The patient, in desperation, asks if the NP can perform another biopsy or if he can use stronger medications so he can be cured. Upon examination, the Nurse Practitioner (NP) observes multiple superficial erosions, most likely excoriations, of his upper and lower extremities. Additionally, there are some overlying crusts and erythema indicating a secondary infection. During the previous visit, the NP recommended a psychiatric consultation to the patient who declined, expressing confusion as to why he should see a psychiatrist for a skin condition.
DP is believed to occur when patients react to delusional cutaneous manifestations by scratching and picking at their skin (Wong and Koo, 2013). While some dermatologists propose an underlying primary disease, most support the view that DP is a psychiatric condition and should be treated accordingly. The Centers for Disease Control and Prevention (CDC) are conducting research on DP and its dermatopathology to understand potential contributing factors to the illness.
Legal Dilemmas
Complying with the patients’ request for another cutaneous skin biopsy without new supporting evidence could lead to accusations of health care fraud. This agreement to perform the biopsy may be perceived as an intent to deceive by the payer. Fraud occurs when a person knowingly engages in an act to achieve monetary gain. The prosecution of fraud can occur at both civil and criminal levels, resulting in fines and/or sanctions against the offenders. Additionally, the medical necessity of the biopsy could be challenged and considered an act of abuse. Fraud and abuse often occur together and consequently have similar repercussions.
Legal Reasoning Constructs
Understanding the law involves comprehending its effects and perspective. Legal reasoning is divided into two areas: defining law and determining case decisions by analyzing previous cases and the content of the law (Comock, 2011).
Interpretation in Legal Reasoning
When assessing the NP’s endeavor to address a patient with parasitosis, it is crucial to recognize the legal implications and repercussions entailed. The assessment of potential treatment options takes into account the patient’s possible reactions, categorizing this scenario under consequential rules. Unlike regulatory law, dermatologists have the authority to prescribe antipsychotic medications if they deem it appropriate. Previous instances have established various viable treatment choices, empowering physicians to opt for the most fitting option considering the particular circumstances of each patient.
Coherence in Legal Reasoning
Legal reasoning is consistent because it can clarify the process of decision-making (Dickson, 2010). The NP’s decision to adopt a multidisciplinary approach to treatment adheres to the fundamental issues involved. The patient is perceived as unstable and requiring both psychiatric and primary medical care for an obvious infection. These two diagnoses are taken into account during the treatment planning phase.
Logic in Legal Reasoning
When evaluating a case, the NP must take into account that performing an unnecessary biopsy would support illogical reasoning in this situation. Fraudulent activity is when someone knowingly engages in an act to gain money (Theoharris, 2013). Furthermore, such an act undermines the principle of nonmaleficence because the biopsy would harm the patient by causing him unnecessary pain (Schatzberg & Nemeroff, 2009).
Case Law
The term ‘case law’ refers to the decisions and interpretations made by judges when they decide on legal issues (LAWS, 2013). Dermatologists must be knowledgeable about antipsychotic medications due to a significant number of patients with skin disease complicated by a psychiatric condition (Ghosh, Behere, Sharma & Sreejayan, 2013). Although traditional dermatology may not prioritize psychiatric management, cases like this one can justify its implementation. Published literature can offer support for the application of ethical-legal standards.
Legal Analysis
It is crucial for advanced practice nurses to understand legal analysis in the context of medical decision-making. It is important to consider the legal consequences of our actions and carefully assess the facts before making evidence-based decisions (Klaassen, Smith & Witt, 2011). As nurse practitioners, we must fully comprehend our obligations in diagnosing and treating intricate conditions. Our analysis should be based on current knowledge of treatment parameters and accepted protocols. Moreover, it is necessary to clearly define feasibility and establish goals to justify our treatment actions.
Ethical Dilemmas
When treating delusional patients with DP, practitioners may encounter difficulties due to the patient’s limited understanding of their condition. If practitioners follow the patient’s request and prescribe an anti-parasitic medication, it could compromise the ethical principle of beneficence as it would not be beneficial. Additionally, if practitioners withhold complete disclosure about the disease to prevent distress, they fail to ensure transparency and may infringe on the patient’s autonomy. Lastly, prescribing an anti-parasitic medication without evidence of a parasitic disease could be seen as misleading or dishonest, potentially violating the ethical principle of veracity.
Ethical Reasoning
According to the Association of American Colleges and Universities (2013), ethical reasoning entails the analysis of human conduct. Gaining a deep understanding of ethical reasoning involves examining its function, logic, and clearly defining the essential elements of the reasoning process to prevent corruption. In the healthcare industry, ethical reasoning is particularly important as caregivers’ decisions affect others’ well-being and shape their perception of moral responsibility. It is through actions rather than words that the principles of ethics are demonstrated (Elder & Paul, 2011).
The Role of Ethical Reasoning
When analyzing ethical reasoning, it becomes possible to comprehend that through examining the logic behind prospective ethical choices, individuals can incorporate their own moral principles into the given circumstances. This process allows for the establishment of a framework within which the ethical predicament can be situated.
The creation of the scenario enables the decision maker to analyze their choices and understand the consequences. By excluding other irrelevant factors, one can concentrate on the fundamental ethical principles at hand and evaluate the possibilities objectively. This is the essence of ethical reasoning. When considering treatment options, the NP should adhere to the ethical principle that governs nursing practice. Evaluating the medical advantages versus potential drawbacks should serve as a guide for the NP during the decision making process.
The Problem of Pseudo-Ethics
Ethics can become intertwined with various modes of thought, resulting in decisions that are influenced by factors such as religion and law. Given the diverse forms of religion, each one may have its own distinct guiding principles. Typically, the specific beliefs held by a religious community are rooted in spirituality rather than ethical principles.
Laws are created in legal circles to declare specific actions as unlawful. The legality of an action is not decided based on ethical principles. Allowing religion and law to intertwine may result in decisions that are influenced by personal beliefs rather than ethical principles. One example of a decision affected by pseudo ethical ideals is the NP’s refusal to consider antipsychotic medication due to religious beliefs that forbid their usage.
Elements of Ethical Reasoning
Ethical reasoning in nursing involves the nurse practitioner (NP) recognizing and understanding their role in addressing issues related to patients with parasitosis. Prior to making any decisions regarding treatment, it is important for the NP to acknowledge any assumptions they may have and gather data to either confirm or question those assumptions. Additionally, in order to maintain a positive therapeutic relationship, the NP must also take into account the emotions and perceptions of the patients while explaining the concepts involved in the reasoning process (Valentine & Bateman, 2011). To establish an appropriate treatment plan, it is essential for the NP to evaluate whether their reasoning aligns with available information and consider potential consequences.
Logic of Ethical Reasoning
Ethical reasoning is essential in nursing as it plays a significant role in shaping the profession and ensuring high-quality care. When faced with decisions regarding patients, it is crucial to thoroughly evaluate ethical dilemmas and their potential outcomes. In the scenario of a patient suffering from parasitosis, the nurse practitioner (NP) must adhere to ethical principles such as beneficence, nonmaleficence, and justice. Moreover, taking into account the patient’s delusional state, the NP needs to determine if autonomy may be compromised. Consequently, prioritizing treatment for psychosis can be justified as it ultimately promotes autonomy for the patient.
Advantages and disadvantages of ethical reasoning.
The benefits of ethical reasoning outweigh any drawbacks because it is based on moral conduct and responsibility (Bradley, Monarch, & Bhimji, 2013). The emphasis on beneficence shows the importance of ethics in the decision-making process of nurse practitioners and supports the actions taken. Ethical reasoning also highlights rationality, but some argue that it can obscure the issues by being subjective. By limiting choices to right and wrong, nurse practitioners may fail to consider other viable options like combination therapy for patients.
A Decision on Treatment
When faced with this scenario, it is crucial for the NP to carefully consider the available treatment options and acknowledge the involvement of multiple disciplines. Establishing a trusting relationship between the provider and the psychiatric patient is essential in developing an effective treatment plan. The narrative approach involves actively engaging with the patient to gain insight into their life experiences (Wallis, Burns and Capdevila, 2010). By offering support and maintaining non-confrontational communication, clinicians can gather valuable information that will inform their decision-making process when selecting appropriate treatments.
The standard medical evaluation or interview is important for gathering necessary information for the narrative approach. By understanding the patient as a whole, the NP can see the patients’ symptoms from their perspective. This allows for a deeper insight into how the patient may feel about discussing their issues with another practitioner, like a psychiatrist. Acknowledging the patients’ suffering and discussing their feelings about different treatments is crucial in the narrative approach (Sandoz, LoPiccolo, Kunsit and Tausk, 2008). Ultimately, this may lead to the patient being more open to a multidisciplinary treatment approach involving dermatologists, psychiatrists, and counselors.
Conclusion
The decision making process can be very complex and involved, as demonstrated by this outline of ethical and legal issues. It can be a challenge for advanced practice nurses, in any setting, to consider both the legality and ethical principles when making decisions. Advanced practice nurses need to have ethical thinking skills and a familiarity with legal challenges so that their decisions reflect the humanity of healthcare and its impact on future practice. Engaging in critical thinking during situations that challenge our ethical and legal obligations allows us to reason and make well-informed decisions.
References
- Association of American Colleges and Universities. (2013). Ethical reasoning value rubric. Retrieved from: www.aacu.org/value/rubrics/pdf/ethicalreasoning.pdf
- Bradley, S., Monarch, K., & Bhimji, S.S. (2013). Healthcare fraud. Nurse.com. Retrieved from: http://ce.nurse.com/RetailCourseView.aspx?CourseNum=ce158-60&page=2&IsA=1
- Comock, M. (2011). Legal definitions of accountability, responsibility and liability. Nursing Children and Young People, 23(3), 25-26.
- Dickson, J. (2010). Interpretation and coherence in legal reasoning. Stanford Encyclopedia of Philosophy. Retrieved from http://plato.stanford.edu/archives/Spr2010enteries/legal_reas_interpret/
- Elder, L., & Paul, R. (2012). Ethical reasoning essential to education. Foundation for Critical Thinking. Retrieved from: www.criticalthining.org
- Ghosh, S., Behere, R.V., Sharma, P.S.V.N., & Sreejayan, K. (2013). Psychiatric evaluation in dermatology. Indian Journal of Dermatology, 58(1), 39-43.
- Klaassen, J., Smith, K.V., & Witt, J. (2011). The new nexus: Legal concept instruction to nursing students, teaching-learning frameworks, and high fidelity human stimulation. Journal of Nursing Law, 14(3-4), 85-90.
- LAWS. (2013). An easy guide to case law. Retrieved from: http://cases.laws.com/case-law Schatzberg, A.F., & Nemeroff, C.C. (2009). Textbook of Psycho-pharmacology (4th ed). Arlington, VA: American Psychological Association.
- Theoharris, M. (2013). Health care fraud. NOLO. Retrieved from: http://www.criminaldefenselawyer.com/crime-penalties/federal/Healthcare-Fraud.htm
- Valentine, S., & Bateman, C. (2011). The impact of ethical ideologies, moral intensity, and social context on sales-based ethical reasoning. Journal of Business Ethics, 102(1), 155-168.
