Introduction be explored before the process of decision making


an advanced practice nurse, one is bound to be faced with various ethical legal
dilemmas that in most cases require urgent decision making that involve both
moral and ethical considerations. Ethical dilemmas are basically situations
where there are two available courses of action that completely contradict each
other. The nurse has no choice but to make a decision between the two choices
because each of the two decision choices is equally urgent and each of them
seems to be the right one. This is what makes dealing with ethical legal
dilemmas very stressful for both new nurses and experienced ones. It is thus
noteworthy that as much as advanced practice nurses have a medical
responsibility to provide care, they are also expected to make decision making
that is independent because they are in authority roles. Some of the existing
ethical dilemmas usually fall in the varieties of treatment withdrawal versus
maintenance, pro-life versus pro-choice, the quality of life versus the
quantity of life, and non-euthanasia versus euthanasia (Garity, 2009).

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paper addresses the ethical legal dilemma of informed consent versus the right
to refusal by the patient. Here, the
patient’s autonomy, human rights, informed refusal and consent come into play
(Appelbaum, 2007). Informed consent can be defined as a situation where a
patient that is undoubtedly informed wants to participate in the choices and
decisions that are being made about his or her health while informed refusal, on the other hand, happens when the
risks appertaining to a certain mode of treatment or the treatment itself are
rejected based on the risks they pose to
the patient’s health and wellbeing in general (Appelbaum, 2007). In such a
case, the ethical aspects of deontology and consequentialism are to be explored
before the process of decision making commences.

The Dilemma and Decision Making and Violation

ethical dilemma for this paper will involve a seventy year old man that is
admitted to the hospital and is currently
experiencing an ischemic attack. The patient is still in sound mind and can make
his own decisions but has exhibited characteristics of continuously becoming
weak and cannot effectively swallow after being affected by the stroke, and so he is very uncooperative when it
comes to taking treatment. His power of attorney, who is his son has agreed to
a Percutaneous Endoscopic Gastrostomy (PEG) through phone but the man declines
the PEG tube insertion because of the health risks posed by these tubes and
prefers to have homecare with hospice. He does not want to contract ventilator associated
pneumonia as he is well informed of the health risks these tubes have on
patients. The assessment done by the nurse indicates that the patient can make
his own decisions. Additionally, his son also agrees with the decision made by
the patient. From the ethical perspective, the consequentialist theory and
deontology can be applied in the decision making of this case. According to
deontology as Bingham (2012) puts it, an emphasis is placed on some actions as
being inherently wrong or right based on what an individual ought to do as per
their obligations and duties without considering the outcome. The
consequentialist theory, on the other hand,
looks at the consequences of the actions and chooses one that yields the least
bad and the best. Legally, the rights of
the patient, in this case, are protected
by the Patient’s Self Determination Act of 1990 given the fact that he is in a
position to make his own decisions (Hamric et al., 2013).

violated principle or ethical theory, in this
case, would be the theory of consequentialist and that of deontology if
PEG tube insertion is done. Consequentialism can be used to justify ignoring
the patient if the outcomes of the decision are to cause more bad than good. Also,
the Patient Self Determination Act of 1990 which includes the patient’s right
to refuse being treated if the patient has been determined to be able to make
his own decisions. The offences would thus be a tort of battery if a procedure is done on the patient without their

The Applied Legal Principles and Related Case

a consent that is legally valid, the decision making capacity is a very
important condition. The right of treatment refusal and consent laws is
underpinned by the respect for autonomy principle. Dealing with a patient
without their consent is a criminal offence referred to as the tort of battery
or assault (Bingham, 2012). The decision made by a competent patient that has
been determined to be in a position to make their own decisions has to, therefore, be respected regardless of
whether or not it seems irrational or uninformed.  

related real case in this patient’s situation is that of Lane v Candura (1978),
where Candura was a 77 year old widow that suffered from gangrene in her lower
right foot. Her physician recommended that the leg be amputated but she failed to consent to that decision (Glantz,
1978). This forced her daughter Lane to file a petition in court with an aim of
being appointed as an authority on her mother’s behalf in order that she consents
to the amputation procedure. It was established by the court that Candura was
in a position to make her own decisions and so her leg was not to be amputated
unless she agrees to it (Glantz, 1978). In my case above, the patient is in a
position to make his own decisions and is even supported by his son who happens
to be his power of attorney.

Legal and Ethical Reasoning and Solutions to the
Ethical- Legal Dilemma

legal reasons are derived from the law while moral reasons are as a result of moral
reasoning or the results of a moral conflict deliberation. The two have been
established to generate broad unending discussions and usually enhance decision
making that is autonomous according to the patient’s human rights (Blair, 2015).
They are also the genesis of all ethical dilemmas in advanced practice nursing.
Dilemmas occur when the nurse is forced to respect the autonomy of the patient
even if the decisions that are being made by the patient could result in serious damage. In this case, it can also be
argued that the patient’s decisions have to be ignored because the results of
the patient’s decisions are extremely harmful. It is however not ethically
right for a nurse to override the decisions made by a patient that has been
established to be competent enough to make his own decisions. According to
Beauchamp and Childress (2001), nurses are obligated to respect the patient’s autonomy
and one of the ways in which this can be done is by acknowledging that they
have the right to act on their health as they please based on their beliefs and
values. An advanced practice nurse should,
therefore, include the patient’s perspective in their analysis of the
conflict there is between ethical principles has to be considered.


of the recommendations towards the resolution of moral distress for nurses could
be the involvement of the patient’s family, explain to the patient clearly the
benefits and risks of the procedure in place so that the patient makes a
decision from a well-informed point of view and lastly a multidisciplinary team
has to be put in place to work alongside with the nurse so that the moral distress
is significantly reduced by the help rendered by the team during decision


it is noteworthy that thorough training on ethics and legal principles are paramount for all advanced practice nurses
as it governs all their decision making scenarios when dealing with patients. The
knowledge is also important as it enables the nurses to respect the patient’s rights while identifying the moral conflicts
and issues at play in most cases.