As previously mentioned, a dilemma refers to a conflict between two alternatives. In such instances, one’s moral decision is to choose the lesser evil of the two. However, various preventive strategies are available to help nurses anticipate or avoid certain kinds of ethical dilemmas.
Frequently, dilemmas occur when the health care practition-ers are unsure of the patient’s wishes because the person is un-conscious or too cognitively impaired to communicate directly. One famous court case in this area of clinical ethics is that of Nancy Cruzan. Cruzan was a young woman involved in a single-car crash, after which she remained in a persistent vegetative state. Her family endured a 3-year legal battle to have her feeding tube removed so that she could be allowed to die. The U.S. Supreme Court decided that a state could require “clear and convincing evidence” of the patient’s wishes before withdrawing life support. This ruling and the public response to it served as an impetus for legislation on advance directives, entitled the Patient Self-Determination Act, which became effective in December 1991. The intent of this legislation is to encourage people to prepare ad-vance directives in which they indicate their wishes concerning the degree of supportive care to be provided if they become inca-pacitated. The regulatory language is quite broad and allows for different institutions to have latitude in implementing the person’s directives. This legislation does not require a patient to have an advance directive, but it does require that the patient be informed about them by the staff of the health care facility. Consequently, this is an area where nursing can play a significant role in patient education.
Advance directives are legal documents that specify a patient’s wishes before hospitalization and provide valuable information that may assist health care providers in decision making. A liv-ing will is one type of advance directive. In most situations, liv-ing wills are limited to situations in which the patient’s medical condition is deemed terminal. Because it is difficult to define “terminal” accurately, the living will is not always honored. An-other potential drawback to the living will is that these docu-ments are frequently written while the person is in good health. It is not unusual for people to change their minds as their illness progresses. Therefore, the patient retains the option to nullify the document.
Another type of advance directive is the durable power of at-torney for health care, in which the patient identifies another in-dividual to make health care decisions on his or her behalf. In this type of directive, the patient may have clarified his or her wishes concerning a variety of medical situations. As such, the power of attorney for health care is a less restrictive type of advance direc-tive. Laws concerning advance directives vary among state juris-dictions. Even in states where these documents are not legally binding, however, they provide helpful information and assist health care providers to determine the patient’s prior expressed wishes in situations where this information can no longer be obtained directly.
Institutional ethics committees, which exist in many hospi-tals to assist practitioners with ethical dilemmas, also aid in preventive ethics. The purpose of these multidisciplinary com-mittees varies among institutions. In some hospitals, the com-mittee exists solely for the purpose of developing policies; in others it may have a strong educational or consultation focus. Because these committees usually comprise individuals with some advanced training in ethics, they are important resources to the health care team, patient, and family. Nurses with a par-ticular interest or expertise in the area of ethics are valuable members of ethics committees and can serve as valuable re-sources for staff nurses.
The heightened interest in ethical decision making has re-sulted in many continuing education programs, ranging from small seminars or workshops to full-semester courses offered by local colleges or professional organizations. In addition, nursing and medical journals contain articles on ethical issues, and nu-merous textbooks on clinical ethics or nursing ethics are avail-able. These are valuable resources because they cover the ethical theory and dilemmas of practice in greater depth. The ANA also has publications available to assist nurses with ethical decision making.