Nursing Ethical Dilemma: Paternalism overrides autonomy

Nurse A was on a night shift and one of her patients was Mr. X who was aware and alert but had multiple conditions and was highly dependent being incontinent of bowel motion and urine. Nurse A came to check Mr. X's vital signs and afterwards she checked Mr X's pad. Nurse A found that his pad was full of urine and stool. Nurse A explained to Mr. X that she was going to clean and change his pad in bed as he was wet. However, Mr. X refused to be cleaned and changed in bed as he wanted to go back to sleep.

The issue of autonomy is clearly relevant here where the patient is empowered to make his own decisions about his health and hygiene (Daly, Speedy & Jackson, 2010). However, the principle of beneficence is also clearly relevant (Daly, Speedy & Jackson, 2010). The whole reason for instituting on washing in bed was because it is believed that it is good to promote hygiene, which means Nurse A was doing something good and providing benefit for the patient (Daly, Speedy & Jackson, 2010). In this case, as part of nursing care Nurse A was also ensuring that her patient was comfortable and did not have to put up sleeping in his bed with wet pad and the smell of urine and stool. It was also Nurse A's responsibility to maintain Mr X's good hygiene. Therefore, Nurse A insisted and carried on cleaning and changing Mr. X's pad even though Mr. X refused and was not happy.

Later on, Nurse A had to give Mr. X's insulin as he was diabetic and his blood sugar level was high. She explained that she had to inject his insulin subcutaneously (under the skin) into his abdomen. However, Mr. X again denied, he had the right to refused to treatment but Nurse A continued to perform an injection to prevent hyperglycemia which can lead to ketoacidocis if not treated in time. In this scenario, Nurse A had to do her duty to care influenced by the nursing code of ethics however, autonomy may have been ignored as a result of paternalism, beneficence and non-maleficence. It appears that autonomy can be a conflicting issue against beneficence and non-maleficence because some patients may not want to be cared or treated even if healthcare professionals or nurses thinks or believe that what is best for them has to be done in order to prevent future harm and possible complications.

In this case the beneficence and non maleficence may spill over into denial of Mr. X's autonomy. The nurse was obviously acting paternalistically, whereby she was doing what she thought was best for Mr. X's health and hygiene even though he did not agree to be injected with insulin for his blood sugar and refused to be cleaned and changed. This case clearly shows that paternalism is best for her patient’s needs even though it overrides a competent patient's explicit wishes and violates his autonomy.

Reference:
Daly, J., Speedy, S., & Jackson, D. (2010). Contexts of nursing (3rd ed.). New South Wales, Australia: Elsevier.