Ethics in Practice Summative

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Philosophy

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Dec 6, 2023

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1 Ethics in Practice: “Our Pregnant Daughter Didn’t Want This” Annette Duque NSG 426: Integrity in Practice: Ethic and Legal Considerations University of Phoenix November 13, 2023 Dr. Stephanie Merck

2 Ethics in Practice: “Our Pregnant Daughter Didn’t Want This” The case study titled “Our Pregnant Daughter Didn’t Want This”, brings to light the ethical and legal issues of upholding a woman’s advanced directives when pregnancy is a factor (Rosell, 2022). In this case, pregnant 29-year-old Janet and her husband Jack were on their way home from an appointment when they were involved in an accident. Janet suffered a massive head injury which left her in a vegetative state and Jack succumbed to his injuries. Before the accident, Janet finalized an advance directive indicating her wish to not be subjected to any means of life-supporting therapies. Her parents respected her decision and decided to move forward with hospice care. In the State of Kansas, pregnancy renders the advance directive ineffective, resulting in legal and ethical considerations that one must consider when determining the right thing to do. Ethical Issues, Ethical Considerations, and Ethical Principles An advance directive is a legal document that not only guides medical staff in decision- making but also takes away the uncertainty families face with making decisions without knowing what to do. In medical practice, four ethical principles should be followed: non- maleficence, beneficence, justice, and patient autonomy. The principle of patient autonomy outlines the provider’s moral obligation to respect the patient’s decisions regarding medical interventions (Ahmed et al., 2020). The physician in this case must practice beneficence, promoting what is best for the patient by upholding her wishes. If the physician permits the pregnancy to continue, this would not be practicing non-maleficence, which is upholding their duty to not harm the patient. Furthermore, ignoring the advance directive infringes on the

3 patient’s right to refuse treatment or other medical interventions throughout the pregnancy (Sperling, 2020). Any complications that arise during pregnancy may require medication or invasive interventions to preserve the life of the patient and the fetus. These issues can cause moral distress among the staff and the family. The physician and the nurse have a moral obligation to the patient. Additional Information and Legal Considerations Advance directives were designed to protect a patient’s autonomy. In the United States, thirty-eight states include pregnancy as a condition that influences an incapacitated woman’s advance directive (DeMartino et al., 2019). The State of Kansas is one of twenty-five states that invalidates a woman’s advance directive if she is pregnant (DeMartino et al., 2019). Regardless of the patient’s wishes, those twenty-five states eliminate the pregnant patient’s rights and only protect the fetus. Consequently, the incapacitated pregnant woman is forced to receive life- sustaining treatment until she gives birth, negating her autonomy. The principle of justice prioritizes the patient’s legal rights and respect for the law (Ahmed et al., 2020). In this case, the advance directive that should be followed is complicated by the State of Kansas’ law nullifying the advance directive. Furthermore, ethical questions surround resource allocation for the care of Janet and her fetus. The cost of caring for an incapacitated person on life support will require many resources and increased staff support to continuously monitor the patient and her fetus. Janet’s parents may also face legal issues, emotional challenges, and the financial burden of caring for Janet’s child. Alternative Options

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4 In this scenario, Janet appears to be about nine weeks pregnant. With Janet being so early in her pregnancy, the fetus is not considered viable until twenty-four weeks. Taking this into consideration, Janet’s advance directive should be followed. Janet’s fetus has many more months of development, and this creates considerable risks such as infections, circulatory instability, diabetes insipidus, and thermal variability (Dodaro et al., 2021). The risk of harm to the fetus and the mother is significant due to these possible factors. Therefore, the first option is to uphold the advance directive. If Janet’s fetus was closer to viability, the physician could be accused of causing harm to the baby. In that case, it may be appropriate to perform life- sustaining therapies to allow the fetus to continue to term. Position and Justification My position is that Janet’s wishes in her advance directive be upheld to respect her autonomy and for the greater good of all patients who may be in a similar situation. This position is important, needed, and beneficial for vulnerable populations because it not only supports the nurse’s role of protecting the patient’s best interests but also protects how the general population views the nurse’s role in protecting their rights. The legal and ethical responsibilities do not align with each other. While ethically, Janet’s right should be upheld, doing so would go against Kansas state law. Actions must be taken to ensure the appropriate outcome for Janet and that would require seeking legal assistance to advocate for Janet. Physicians and nurses have an obligation and duty to do what is best for Janet by upholding her advance directive and therefore should consult with an ethics and legal

5 committee for guidance. Knowing the implication of swaying one way over the other is essential for making a decision. Implementing the Plan Fetal viability is the strongest argument that can be made in support of my position. Roughly 40% percent of infant deaths occur before twenty-seven weeks gestation (Tucker Edmonds et al., 2019). Furthermore, two-thirds of the surviving neonates will suffer from neurological disabilities (Tucker Edmonds et al., 2019). A child with moderate to severe disabilities can result in lifelong pain and suffering, as well as financial hardship for the family. According to Sperling (2020), most previous cases have shown that gestation can be prolonged for 2-6 weeks. Given that Janet is about nine weeks along, six more weeks would not give the fetus any better chance of lung maturity that would ensure fetal viability outside the womb. Knowing this, life-sustaining therapies would be discontinued, and the patient would be transferred to hospice. Conclusion Legal and ethical considerations are essential elements to be considered when faced with an ethical dilemma. Janet had an advance directive in place before learning of her pregnancy. Regardless, medical staff were unable to honor her advance directive without first seeking legal and ethical advice in her case. Most states in the United States have limitations regarding pregnancy in an advance directive, with many states nullifying the advance directive if the patient is pregnant. Women need to research their state's laws and plan accordingly to ensure the autonomous decisions made are upheld.

6 References Ahmed, A., Ali, H. S., & Mahmoud, M. A. (2020). Prioritizing Well-being of Patients through Consideration of Ethical Principles in Healthcare Settings: Concepts and Practices. Systematic Reviews in Pharmacy , 11 (5), 643–648. DeMartino, E. S., Sperry, B. P., Doyle, C. K., Chor, J., Kramer, D. B., Dudzinski, D. M., & Mueller, P. S. (2019). US State Regulation of Decisions for Pregnant Women Without Decisional Capacity. JAMA , 321 (16), 1629–1631. https://doi.org/10.1001/jama.2019.2587 Dodaro, M. G., Seidenari, A., Marino, I. R., Berghella, V., & Bellussi, F. (2021). Brain death in pregnancy: a systematic review focusing on perinatal outcomes. American Journal of Obstetrics and Gynecology . https://doi.org/10.1016/j.ajog.2021.01.033 Rosell, T. (2022, August 5). Case study – Our Pregnant Daughter Didn’t Want This. Center for Practical Bioethics. https://www.practicalbioethics.org/shared-decision-making-and- advance-care-planning/advance-care-planning/case-study-our-pregnant-daughter-didnt- want-this/ Sperling, D. (2020). Should a Patient Who Is Pregnant and Brain Dead Receive Life Support, Despite Objection From Her Appointed Surrogate? AMA Journal of Ethics , 22 (12), E1004–E1009. https://doi.org/10.1001/amajethics.2020.1004

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