While healthcare professionals must frequently make ethical decisions, few comprehensive frameworks exist that can be applied directly to most complicated health situations. The following essay explores the ethical issues surrounding a particular recurring event involving physical coercion having to be applied by hospice staff. The essay begins with discussing the dilemma and proceeds to lay out the core moral issues in a dilemma. Then relevant guidance from national and international legislation is provided. Finally, the situation is viewed and analysed from four leading ethical theories, and possible solutions are detailed.
Emma Jones is 25 and has severe learning disabilities as well as congenital heart disease. She lives with her parents and every two months spends one week in a young adult hospice. When at the hospice, Emma enjoys herself greatly and interacts well with staff and other residents. Her mood and general well-being improve, which lasts for at least a week after returning home. However, Emma finds it distressing and becomes agitated when she must get into a car to travel to and from the hospice. She struggles and tries to get back into the house or hospice. In order to get her into the car, it is necessary to use some restraint or pressure. Her parents and hospice staff wonder whether this restraint is justified under the Mental Capacity Act (2005).
In the case of Emma Jones, the act of physically pressuring her to enter the car is a source of an ethical dilemma for the hospice staff and her parents. An ethical dilemma occurs when a decision must be made that fails to satisfy every ethical consideration concerning the patient. Miliken and Grace (2017) suggested that ethical dilemmas happen when a moral decision arises involving multiple ethically correct alternatives mutually exclusive. The dilemma arises from the inability to satisfy conflicting ethical values. In this case, the relevant ethical values are beneficence, freedom and autonomy. The ethical principle of beneficence can be defined as the paradigm that actions should be taken for the benefit they produce for other people (Scott, 2017). Healthcare staff view the principle as a mandate to always do what benefits the patient. In healthcare and especially in hospice care, one of the main imperatives for the staff is taking positive steps to support patients’ physical and emotional well-being. In Emma’s case, her hospice visits improve her well-being, so the nurse’s choice based on goodwill would ensure that her hospice visits are maintained. However, since Emma refuses to voluntarily get into a car for travelling to and from the hospice, the staff and parents sometimes apply physical restraint/pressure. This violates another ethical principle; respect for the patient’s autonomy (right to self-decision). De Vries and Plaskota (2017) suggest that logical conflict between the mutually exclusive application of ethical principles causes ethical dilemmas. In this case, the principles of beneficence and respect for autonomy can both apply to the problem, but neither can be selected without violating the other one. So, the central dilemma here is “whether to restrict Emma’s autonomy using physical coercion for her medical well-being?”
The UK legislation regarding patient autonomy began in earnest with the Mental Health Act (1983). However, particularly relevant is the proceeding Mental Capacity Act (2005). This act provides a complete legal structure for deciding on behalf of people (over 16 years old) who are deemed lacking the capacity to make those decisions themselves at a certain point in time. The Act’s Section 5 enshrines the standard law policy of necessity and defends those who perform actions of care or treatment for another individual who can be safely evaluated to be lacking capacity in the “best interests” of that person (Cave, 2014). In assessing the person’s best interests, staff should consider non-medical implications on the patient following their decisions (Department of Health, 2010). The same source suggests that staff should regard the beliefs and values of the care receiver (as far as can be retrieved in the event of incapacity), the general condition of the patient, their connections with close others and their spiritual and cultural inclinations (Department of Health, 2010).
In the Mental Capacity Act (2005), restraint is defined as the usage of force on an individual who is resisting, and any form of control or constraint applied to the freedom of movement of the individual, whether or not they are exhibiting signs of resistance (Jones, 2005). The Act also outlines two conditions that must be met to use restraint to be justified. As detailed in section 6.2, the first condition is that the action of applying restraint must only be taken if the performer of the action justifiably believes that it is necessary to prevent the patient from causing harm to themselves (Pettet, 2016). This condition is unmet in Emma’s case because not going to hospice does not cause Emma physical harm. As laid out in section 6.3, the second condition is that the degree and period of restraint/coercion applied must be proportionate to the degree and probability of occurrence of potential harm that the patient is at risk of (Donelly, 2010). If the harm in question is the loss of care benefits to Emma, then the mild restraint can be proportional to the threat. Therefore, the MCA only justifies restraint if it is necessary to prevent the incapacitated patient from causing harm to themselves, if it uses the minimum force necessary and that it is used for the little possible time. In Emma’s case, even though the use of restraint can be said to be proportionate, the fundamental condition that restraint can only be used to prevent harm – is compromised. This is because Emma’s choice of not going to hospice is not actually causing harm; rather, it deprives her of possible benefit. According to UK legislation and international human rights conventions, every person has the right to consent to their treatment. So, it is possible that the actions of the hospice staff may be placed under scrutiny should they be examined under the MCA (2005).
The NMC code lays out advice against the use of restraints by nurses in the Nursing and Midwifery Council code (2015). Section 2.5 states that nursing professionals must always treat the patient’s right to consenting or refusing care with respect and acknowledgement. But the code also accounts for scenarios where the patient’s capacity may be compromised and states that the nurse must make sure that the patient’s best interests are being upheld (Royal College of Nursing, 2017). Section 4.1 of the NMC code states that nurses must strive to reach an equilibrium between their duty to do what is best for the patient and respecting the patient’s autonomy (even when they refuse care) (NMC, 2015a). Therefore, this centrist view would suggest that the hospice staff strike a balanced approach to dealing with the situation. However, which principles take priority are still left ambiguous. A review of moral theories relevant to healthcare may offer more specific guidelines for this case.
Three parties mostly face the situation; the patient, their parents and hospice staff. However, external parties who view this situation may have different things to say about it. The patient, Emma Jones, is a 25-year old who suffers from learning disabilities. Emma’s issue is that she doesn’t like to get inside cars, which is necessary to take her to and from the hospice. She may feel threatened or upset by being pressured into doing this each time she visits hospice (Tingleff et al., 2017). While it’s true that she shows no signs of remembering this once she reintegrated into the home/hospice surroundings, it could be possible that such events are negatively impacting her feelings of self-worth and diminishing her perception of her relationship with her caregivers (McLaughlin et al., 2016). While such measures are often validated with the necessity of lifesaving, it could be argued that a hospice stay was not necessary for her survival, and the public might view this as an unnecessary pain inflicted on Emma Jones. Since the context of her relationship with the hospice would not be known, witnesses to the event would probably perceive this as unfair and against the wishes of Emma. In such a situation, her parents and hospice staff are in a dilemma indeed. Despite caring about Emma’s well-being, they reluctantly created a situation where Emma’s wishes were being forcefully violated, albeit for a few minutes. Her parents viewed this as an uncomfortable but necessary part of Emma’s care. They thought of Emma’s improved state after the visit to justify that this helps her emotionally and psychologically. The hospice staff have faced a similar situation with other patients in their time caring for young adults afflicted with learning disabilities. They have heard that these sorts of measures are justified under the Mental Capacity Act but are unsure about the specifics.
Modern Utilitarianism was founded by Jeremy Bentham and John Stuart Mill in the 18th century but had roots in the ideas of the Greek philosopher Epicurus (Barber, 2016). The essence of the idea is that all actions should be measured by the pleasure or happiness they create. Applied equally to everyone, this theory says that we should all pursue the greatest pleasure for the highest number of people, known as ‘the utility principle’ (Felzmann, 2017). This runs in contrast to egoistical theories, which suggest that people should pursue their personal goals/ pleasures. Although it sounds simple enough, utilitarianism is a moral theory that demands the right action even when it is difficult to the self and can be pretty challenging to abide by in certain situations. In this case, the parents and hospice staff could either allow Emma not to enter the car and continue staying at her home, which would change nothing. Or they could coerce her into making the journey to the hospice, which would give Emma about two weeks of improved well-being every two months. In terms of the utility principle, the hospice staff and parents are morally obligated to coerce Emma into getting into the car. Because even if it produces a short period of discomfort for her, it leads to a long period of emotional reward, and therefore happiness, for Emma. This ethical theory coincides with the personal moral beliefs of Emma’s parents and the nurses because they justify their acts of coercion with the belief that it is for the greater good of others, in this case, Emma herself.
This theory focuses on right action rather than good consequences, such as utilitarianism, which is a consequentialist theory. It dictates that any action is proper only if it abides by the moral code of the particular theory, regardless of the consequences. This makes this theory far less permissive. Immanuel Kant, considered a pioneer of this theory, argued that moral acts are either right or wrong on principle. And that humans must do good regardless of situational factors (Barber, 2016). He suggested we adopt the idea of a “Categorical imperative” – a directive that each of us must act only in ways that we would want to become universal laws (Tepper, 2017). In Emma’s case, the action in question is coercion by physical force. According to the categorical imperative, this would be morally wrong because no one would want the use of physical coercion to become a universal law. This principle aligns with viewing Emma as an adult with the same rights to self-determination as everyone else. It might be akin to what a passerby pondering the situation or the uninformed public may think in this situation. But it runs contrary to the actions of Emma’s parents and the hospice staff, thereby implicating them in immoral acts. On the other hand, it could be argued that the action in question is whether to use momentary physical coercion for the more significant benefit of an individual who is unable to make the best decisions for themselves. By viewing in this manner, the act can be treated in light of its selfless root cause, improving the wellbeing of Emma. It could be argued that such decisions should be taken on behalf of incapacitated individuals every time and therefore could pass as universally applicable, thereby getting justified under Kant’s categorical imperative. In this context, the same view is shared by the legislation in the UK, including the Mental Capacity Act, that allows decisions to be taken on behalf of incapacitated patients, as long as they are in their best interests.
Owing to its roots in Aristotle and Plato of Ancient Greece, the theory of virtue ethics is formed around virtues, which are moral principles that can be discovered by humans through rationality and acquired by practice in a community of character (Scott, 2017). Unlike utilitarianism, which focuses on consequences, and deontology focuses on action, virtue ethics focuses on character. According to this theory, doing the right thing is achieved by becoming the right person with the proper virtues. Virtues are simply tendencies/ dispositions that are good. For example, a care professional who witnesses patient mistreatment by a colleague should confront them and exhibit the virtue of courage. These virtues can be gained through practice, and the theory suggests that following particular good virtues will bring happiness/ flourishing in life (Jones, 2015). Virtues that are particularly relevant to the role of healthcare professionals include integrity, compassion, respectfulness and trustworthiness (Franco et al., 2015). In light of these virtues, the decision to use coercive pressure/ restraint on Emma can be seen as impeding the virtue of respectfulness. However, suppose the parents and hospice staff involved practice respectfulness in their lives. In that case, this action will be viewed in the context of their more incredible experiences, as virtue ethics focuses on characters. In that light, the specific action of coercing Emma to get into the car may not be unethical if the staff view it as the right course and in line with their development of virtues in their career and lives, such as compassion.
Although not a moral theory in the same way as the previous ones, principlism is the most widely used ethical framework in healthcare today (Barber, 2016). First outlined as four principles of biomedical ethics by Beauchamp and Childress (Rauprich, 2008), principlism advocates morality based on shared principles that most people accept. Specifically, these are the principles of autonomy, beneficence, non-maleficence and justice. These principles are drawn from each of the ethical frameworks discussed before and provide practical tools for ethical decision-making. In Emma’s case, the principles of autonomy, beneficence and justice are of particular relevance. The decision to force her to come to hospice helps her emotionally and physiologically, thereby ensuring that the staff follows the beneficence principle (doing what is best for Emma). On the other hand, Emma’s right to make her own decisions are being violated each time she is being forced to enter a car to go to hospice. The same can be said for the justice principle, which states that everyone should be treated equally and without discrimination. It can be argued that Emma’s wishes are not being respected because of her learning disabilities. So, in essence, she is being discriminated against. This theory, therefore, produces contradictory guidelines since both beneficence and autonomy/ justice cannot be maintained in this dilemma. Since the principles are not part of a priority-based hierarchy, it provides no real solution to what the staff or parents should do. Since this theory is widely popular in healthcare, it might explain why the hospice staff were confused about the moral implications of their actions.
The different ways in which each individual reacts to ethical dilemmas have a lot to do with their perceptions and identity. For example, one study found that female nurses were more concerned about the morality of using restraints on patients compared to male nurses (Korkeilla et al., 2016). Another essential variable is the cultural and religious background of the individual. Religions tend to have their moral codes, and often these profoundly influence even the professional lives of followers. For example, Christianity advocates for following virtue ethics, while Islam has a very detailed ethical guideline inside its religious texts (Ismail, 2016). Similarly, culture determines how we view moral dilemmas to a great degree. For example, autonomy and independence are given a lot of weight in western cultures, compared to more collectivist cultures of Asia. So, an attendant of Asian culture may feel less conflicted about coercing Emma and may even feel like it is a clear moral choice. That is because paternalistic and collectivist mindsets have prioritised other things over individual freedom and autonomy. The age of the individual is also a possible variable. Another study found that younger and less experienced nurses suffered more from ethical dilemmas and guilt than their older colleagues (Leahy-Warren et al., 2018).
Even though the principles-based approach has become very popular in healthcare over recent years, it can often lead to dead-end situations with contradictory principles, such as in this case, Through the analysis of relevant legislation and professional codes and the application of theoretical frameworks of ethics, we were able to provide a comprehensive, multifaceted look at the morally ambiguous decision of coercing adult patients, even if it is perceived to be for their benefit. After analysing the situation through the various lenses of these theories, it can be argued that the literature and legislation point to this practice being unethical. So, the hospice staff should reconsider their practice of coercing Emma Jones into using a car.
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