Medical Ethics: The Case Study


Ethical principles in nursing ensure that clients receive the best care that is in line with their rights. Most health care facilities have principles of professional nursing and ethical frameworks that guide nursing practice. Besides, the practice of nursing is influenced by several ethical and legal guidelines. The case of Mrs. Jolene Tan is an example of the application of ethical guidelines in nursing. This paper uses the ethical decision-making model to determine the recommendations for the ongoing care of Jolene Tan after her decision to decline further treatment.

Problem Statement

Mrs. Tan’s decision to decline further medical or surgical interventions for her condition is a challenge for the nurses and other care providers. This patient is cognitively healthy and makes a decision that may affect her life and that of her family (Emanuel, 2011). Her decision has significant ethical, medical, and social implications. Besides, the decision to decline further treatment has legal implications. The ethical problems include the anticipated suffering if this patient does not receive any medical or surgical attention (Emanuel, 2011).

The medical problems that this patient is likely to encounter include the worsening of her condition and eventual death. Additionally, Mrs. Tan is likely to experience the pain resulting from her deteriorating condition. Aside from the medical problems that may lead to her death, Mrs. Tan is also likely to experience social problems such family conflicts (Berman, 2008). Some of the family members may not go along with her decision and may want her nurses to provide the necessary care (Berman, 2008). The legal implication is that the nurses have to prove that she is cognitively sound to make this decision to decline further treatment (Berman, 2008).


Mrs. Tan’s problem requires thorough history taking, examination and relevant investigations. Some of the relevant questions in history include the duration of the condition, its onset, and progression (Muehlbauer, 2013). Additionally, it is important that the nurse assess any underlying somatic and non-somatic conditions. These help the nurse to plan for the care of this patient during her stay in the ward. Any history of trauma or assault is also important in the management of this patient. The occupation of this patient is also an important contributor to her problem.

On examination, some of the important things to look for include the strength of all the limbs. A reduction in the power of the limbs indicates the areas and the nerves that are affected. Additionally, a general examination shows the overall condition of the patient and the type of care that is necessary to ensure they can live longer (Berman, 2008). Despite the patient declining further treatment, she requires a series of investigations to ensure that she is adequately managed. These include nerve conduction studies, a complete blood count, and renal function tests. Some of the other tests that are necessary include urea, electrolyte and creatinine levels, an evaluation of tumor markers, and psychiatric tests. Imaging modalities such as MRI are also significant in the assessment of this patient.

Ethical Principles

The main ethical principles must be maintained to ensure that the patient’s rights are respected. These include autonomy, beneficence, non-maleficence, and justice (Allmark & Tod, 2009). In autonomy, the patient has made a sane decision to decline further treatment including the insertion of PEG tube. The independent decision by Mrs. Tan has to be respected by the nursing staff and relatives who may want something else for the patient. In addition, the principle of autonomy means that Mrs. Tan gets to make her health decisions without being coerced (Ivanov, & Oden, 2013). However, the nurses have to educate the patient to ensure that she makes an informed decision (Allmark & Tod, 2009).

In beneficence, the patient has to obtain benefits from her treatment (Kuebler & Davis, 2005). In this case, Mrs. Tan opts for no further treatment, and this may not be beneficial to her health. However, nursing professionals and other healthcare workers have the obligation to provide other services that prolong her life (Kuebler & Davis, 2005; Kerridge, Lowe, & McPhee, 1998). The principle of beneficence means that patients receive care that benefits them even when they decline other services (Kangasniemi, Vaismoradi, Jasper, & Turunen, 2013). Even though Mrs. Tan is against PEG, she still requires other supportive services from the nursing staff.

The third ethical principle of nonmaleficence relates to the risks involved and how they can be avoided (McCarthy & Gastmans, 2015). In the case of Mrs. Tan, declining further treatment puts her at risk of death, and she may develop other complications. The relatives should be advised on the alternative therapies for her condition to ensure that she remains healthy and retains her cognition. Additionally, this patient should be accorded the best care before her demise. The risks may be reduced if the patient and her family receive adequate counseling. In addition, the family should get supportive therapies to teach them how to take care of this patient (McCarthy & Gastmans, 2015).

Justice requires that the interests of the different parties are balanced (Kerridge, Lowe, & McPhee, 2005). In this case, the parties involved include Mrs. Tan, her husband and, family, and the healthcare professionals involved in her management (Gelfman & Meier, 2012). All the other parties should meet the primary interests of the patient. In addition, the nursing staff should ensure that this patient is well informed before making her decision (Moşoiu, 2014). According to Buzgová and Ivanová (2011), the family interests should be balanced. Mr. Tan needs to be informed of the condition of his wife and the implications of her decision. On the other hand, the nursing staff and other healthcare workers taking care of this patient should ensure that they record all this information and keep it for future reference.

Ethical Conflicts

There are several ethical conflicts in the case study. The first ethical conflict is the difference between the needs of the patient and those of the nursing staff. While medical professionals and nurses are trained to provide the best care to patients, Mrs. Tan declined further treatment. The nurses are still obliged to provide alternative care for this patient even after her decision provided they inform her (Arthur, 2008). However, they are not allowed to compel her to change her mind but to allow her to make an informed decision.

The other ethical conflict in the case study is balancing the needs of the patient against those of her relatives and family. While the patient does not want further treatment. Her family may insist on having her receive supportive care. In this case, Mrs. Tan may agree to certain aspects of her treatment such as counseling. In addition, this patient may require specialized treatment. The patient’s husband may also require treatment and counseling. Furthermore, the thought of losing this patient if no treatment is provided may contribute to conflict between her and the family.


Different nations have different laws and regulations relating to allowing and refusing treatment (‘Codes and Guidelines’, 2015). Global legal and health bodies such as the WHO also recognize these regulations. In Singapore, the regulations relating to consent and refusing treatment are adopted from the international guidelines (‘Position Statements’, 2015). Health care professionals are required to respect the decisions of patients regarding their treatment options (‘Registration Standards’, 2015). The regulations are in line with the ethical principles that these practitioners are required to follow.

In Australia, some of the existing regulations on the refusal of treatment are embedded in the constitution in the bill of rights. Under the Australian Constitution, individuals have the right to life (‘Western Australian Legislation’, 2015; ‘Codes and Guidelines’, 2015). Additionally, patients have a right to an informed consent before any procedure or treatment option (‘AHPRA’, 2015; Schrems, 2014). The other regulations touching on the refusal of treatment and consenting are included in the ethical guidelines (‘Nursing and Midwifery Board of Australia’, 2015). Consequently, the regulations in Australia on consenting treatment are similar to those in most parts of the world.

Ethical Decision Making

The clinical-ethical decision in the case study is the decision to withhold further treatment for Mrs. Tan in line with her request. Responsibility for the decision includes providing alternative care that the patient may consent to (Makaroff, Storch, Pauly, & Newton, 2014). Since the decision of Mrs. Tan should be respected, she should not have the surgical intervention that was planned. However, she is still entitled to routine counseling to ensure that she can take care of herself and her family. Additionally, this patient should receive alternative management for her disease including supportive care.

An evaluation of Mrs. Tan’s decision to decline further treatment is necessary. The case study describes this patient as being cognitively sound. This factor means that Mrs. Tan’s decisions should be respected by her family and the nursing staff. Consequently, she should not receive any treatment for her condition without her consent. The decision to decline treatment puts this patient at risk of developing complications of her condition and succumbing to it. Additionally, this decision is likely to affect the husband, children, and other close members of her family. However, it is necessary that the decision is respected, and the patient receives alternative forms of management after her education.

In this decision, the patient will not receive specialized surgical care such as the insertion of a percutaneous endoscopic gastrostomy tube (PEG) to assist with her nutrition. The palliative care nurse will also not provide other services that may prolong Mrs. Tan’s life (McLeod-Sordjan, 2014). Any intervention that she wishes to provide to the patient must follow these guidelines and reflect the will of the patient (McLeod-Sordjan, 2014). The patient is aware of the poor prognosis associated with her condition and is prepared for any eventualities such as death. In addition, this patient should not receive further treatment.


In conclusion, Mrs. Tan has chosen not to receive further treatment for her condition despite the poor prognosis. This patient understands the consequences and is prepared for eventual death. Nurses attending to her face several ethical challenges in her care. However, there are ethical guidelines and regulations that govern the provision of health services to such patients as indicated. The four ethical principles discussed are central to the management of this patient.


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