Alice Lam & Christina Shamrock
HPPA-514: Biomedical Ethics
Case-Based Argument from 10/23/19
Patient is an 87-year-old female who has been in a rehabilitation center for the past 2 months for a right hip fracture after a slip and fall in her home. She has been living independently for the past 12 years with her dog. The PA caring for the patient motivates her by emphasizing the need to build her strength in order to care for her dog. The patient’s daughter plans to move her to an assisted living facility after rehab because she believes the patient is too frail to return to independent living. However, the patient is unaware of these arrangements. The daughter asked the PA to conceal these changes from the patient and requested that she stops using the dog as motivation because the facility does not allow pets. The patient has decision-making capacity and is eager to return home to her dog. The daughter and PA have disagreeing ideas of what should be revealed to the patient.
The PA is conflicted whether she should honor the daughter’s request to not tell the patient of the assisted living plans and if she should modify her rehabilitation motivation strategy accordingly. We recommend that the PA does not honor daughter’s request in order to respect the principle of autonomy and beneficence on behalf of the patient. The PA can adjust her motivational strategies based on the final outcome of the living arrangement.
Autonomy is “the right to make independent decisions concerning one’s own life and well-being” (Yeo-Autonomy, 91). Beneficence is a principle based on the practice of providing benefit, which can mean either “preventing/ removing harm or directly producing a good” (Yeo-Beneficence, 103). Health providers are expected to act in a way that maximizes benefits for the patients and minimizes harm (Yeo- Beneficence, 107).
While the principle of beneficence is based on maximizing benefits and minimizing harm, what is considered harm or benefits depends on the person (Yeo – Beneficence, 112). The daughter might view safety and prevention of physical harm as more vital than the comfort of being at home, therefore believes she is acting in the best interest of her mother. However, at this stage of her life, the patient could likely value her independence and pet more than being in a safe environment. While judgement on beneficence is subjective, the PA is obligated promote beneficence on behalf on the patient. The PA feels that concealing this information would provide harm to the patient because it runs the risk of deception and gives false hope.
The daughter practices paternalistic behavior by arranging assisted living for her mother without her permission, assuming that she knows what is best for her. If the PA went along with the daughter’s plan, she would be practicing paternalistic healthcare, which is based on the notion that the healthcare providers know best and should make decisions for the patient (Yeo-Autonomy, 92). Concealing the fact that the patient could be moving to an assisted living facility could cause more harm than good, which negates the principle that health care providers are meant to act in a way that maximizes benefits for the patient.
The patient has decision-making capacity and can appreciate the consequences of her choices and options. Changing the patient’s living situation without discussing it with her violates the patient’s autonomy in regards with free action and authenticity. It infringes autonomy of free action because the patient was not involved in the decision-making process and is subtly being pushed to live in an assisted living facility. Moreover, the decision to live in an assisted living facility that does not allow pets would not be aligned with her character because she values living with her dog. The PA has built a relationship with the patient and understands her values. As her PA, she obligated to be truthful to the patient so that the patient can make autonomous decisions that are aligned with her values and goals of care.
Health professionals have an obligation to help patients make autonomous decision by providing patients with relevant and truthful information (Yeo- Autonomy, 95-96). “Anything other than truthfulness diminishes the patient’s ability to be autonomous” because the patient does not have all the information needed to make an informed decision that is aligned with their character (Tuckett, 505). If the healthcare team and daughter were truthful about the plans for new living arrangement to the patient, then they can all be involved in the shared-decision making process and the patient would not feel as if she was deceived. In fact, “truthfully informed patients” tend to be more cooperative with the plans laid out for them (Tuckett, 505). Quality healthcare providers advocate for the patients by ensuring that patients have all the necessary information in order to make decisions about their life. The PA can assist the patient in making authentically autonomous decisions by discussing the patient’s goal of care and what the patient would like after she is discharged from rehab.
Some may counter by arguing that the PA should conceal this information because it would help the patient continue her progress in rehab. Moreover, the attending physician reports this method has been successful in transitioning elderly patients to assisted living. Finding out potentially distressing news could affect the patient’s emotional status and motivation to recover, and therefore, it would be prudent to withhold the truth until she fully recovers. Furthermore, transitioning the patient to an assisted living facility would reduce the harm of falls/ injuries because there is staff continuously watching over her. As the patient is an elderly female living alone, she is at risk for another fall and could be down for some time until someone visits her. Therefore, concealing this information provides the benefits of rehab progression and easing the transition into assisted living.
The counterargument above relies on the intentions and benefits of safety; however, concealing this information does not directly mean that the patient will progress in rehab or that the transition will be easy. Good intentions are not enough to meet the requirements of beneficence; it also must produce good outcomes (Yeo- Beneficence, 109). Deceptive practices from the family and PA runs the risk of being discovered. It can result in permanent mistrust and feelings of isolation from the patient. If the patient discovers her living arrangements have been changed without her approval and learns that everyone knew about it before she did, the patient could become emotionally withdrawn, which could affect her rehabilitation progress. Furthermore, the mistrust in her family and health care providers could lead to worse outcomes in the future. For example, if the patient has another injury, she might not want to confide in her family or healthcare provider because she no longer trusts them. Lying to the patient about her living arrangements could her compromise her mental and emotional health, which will likely affect her physical health.
Overall, the PA should not feel obligated to honor daughter’s request to conceal the truth from her patient because the patient has a full decision-making capacity and is capable to make decisions on her own. Therefore, by revealing the truth, the PA is respecting the patient’s autonomy and preventing emotional/ mental distress that can be caused by deception. In general, most patients want to the know the truth about their care and the patient in this scenario would likely want to know the truth about her daughter’s plans (Tuckett, 508).
Tuckett, AG. (2004). Truthtelling in clinical practice and the arguments for and against: A review of the literature . Nursing Ethics, 11(5), 500-513.
Yeo, M et al. (2010). Autonomy [selections]. In M Yeo et al. (eds.). Concepts and Cases in Nursing Ethics. [3rd edition] Ontario: Broadview Press, pp. 91-97, 103-109.
Yeo, Michael et al. (2010). Beneficence . In M Yeo et al. (eds.). Concepts and Cases in Nursing Ethics. [3rd edition] Ontario: Broadview Press, pp. 103-116.