SlideShare una empresa de Scribd logo
1 de 20
Descargar para leer sin conexión
Case study: an ethical dilemma involving a dying patient
by Alsacia L. Pacsi
Abstract
Nursing often deals with ethical dilemmas in the clinical arena. A case study demonstrates an ethical dilemma faced
by healthcare providers who care for and treat Jehovah's Witnesses who are placed in a critical situation due to
medical life-threatening situations. A 20-year-old, pregnant, Black Hispanic female presented to the Emergency
Department (ED) in critical condition following a single-vehicle car accident. She exhibited signs and symptoms of
internal bleeding and was advised to have a blood transfusion and emergency surgery in an attempt to save her and
the fetus. She refused to accept blood or blood products and rejected the surgery as well. Her refusal was based on a
fear of blood transfusion due to her belief in Bible scripture. The ethical dilemma presented is whether to respect the
patient's autonomy and compromise standards of care or ignore the patient's wishes in an attempt to save her life.
This paper presents the clinical case, identifies the ethical dilemma, and discusses virtue ethical theory and
principles that apply to this situation.
"Juana" (fictitious name) a 20-year-old, Black Hispanic female, 32 weeks pregnant, was brought to the emergency
department (ED) in an ambulance by the paramedics. She arrived in the ED immobilized on a flat board with a hard
cervical collar in place. Juana was the driver of a sedan involved in a single-vehicle collision. She stated she was
driving at approximately 60 miles per hour on the highway and suddenly lost control of the vehicle and crashed into
a light pole. She also stated her head hit the windshield and shattered the glass. She denied loss of consciousness.
Upon her arrival in the ED, Juana was alert and oriented to person, place, and time and had a Glasgow Coma Scale
of 15/15. Her initial complaints were lightheadedness, weakness, left shoulder pain, and severe abdominal cramping
that started immediately following the car accident. She had a past medical history of sickle cell disease and no
previous pregnancies. Her lungs were clear bilaterally. Juana's heart rate was 90 beats per minute (bpm), her
respiratory rate was 28, and her initial blood pressure (BP) was 130/80, and fetal pulse rate was 90. Once the
cervical spine films were taken and the flat board was removed, her BP reflected orthostatic changes of 100/60 and
pulse of 120 bpm.
Diagnosis and interventions
Juana was placed on a 100% nonrebreather mask. Peripheral intravenous lines were started bilaterally to replace
fluid loss that was indicated by the change in vital signs. It was suspected that she was bleeding internally into her
thoracic or abdominal cavity. Blood specimens were drawn and sent to the laboratory. A hemoglobin of 6 g/dl and
hematocrit of 21% indicated internal bleeding. Ultrasound showed blood in the amniotic cavity and Doppler
confirmed a fetal heart rate of 90 bpm indicating fetal distress. The patient was informed by the medical team of the
critical nature of her condition.
The plan of care for her was an immediate blood transfusion and an emergency cesarean section. Matters became
complicated when Juana informed the medical team that she was a Jehovah's Witness and refused the proposed plan
of care. The physician then recommended the use of alternative blood products. Juana insisted that this was also
against her religion and she refused the alternative treatments being offered. The medical team advised her that
Jehovah's Witnesses could choose certain blood byproducts, such as albumin, cryoprecipitate, and globulin
(Watchtower Bible and Tract Society, 2004).
According to Juana and her husband, both believed that if she accepted the blood transfusion or blood products she
would no longer be a Jehovah's Witness and would be condemned to hell. The husband then presented the physician
with Juana's blood card, created by the Watchtower Bible and Tract Society, the governing organization of Jehovah's
Witnesses. The card stated her advance directives, including the prohibition of blood and blood products.
The beliefs of Jehovah's Witnesses stem from their interpretation of passages from the old testament of the Bible,
which they believe is the inspired word of God (Watchtower, 2004). For example, according to the New World
Translation of the Bible, blood symbolizes the life of the person or animal (Gen.9.36). Revelations (1.5) states, "The
only appropriate use of blood is the sacrificial blood of Jesus." Another passage that Jehovah's Witnesses emphasize
declares, "And whatsoever man there is among you, that eateth any manner of blood, I will even set my face against
that soul that eats blood, and will cut him off from among his people" (Lev.7.10-14).
Juana's condition worsened within 2 hours of admission to the ED. She went into labor and delivered a stillborn
baby boy. She was immediately transferred to the intensive care unit where, despite continued aggressive attempts to
stabilize her, she went into cardiac arrest and died.
The ethical dilemma
This case presents an ethical dilemma, a situation which arises when one must choose between mutually exclusive
alternatives (Beauchamp & Walters, 2003). Decisions may have results that are desirable in some respects and
undesirable in others. In Juana's case, her decision to refuse the blood transfusion had the desired outcome of
allowing her to remain true to her religious beliefs. However, her choice also resulted in her death. If she had
followed the recommendation of the physicians and the team, the desirable outcome would have been possible
survival but would have had the undesired effect of violating her religious principles. The major ethical dilemma
was that by honoring the patient's autonomy and religious beliefs, the physicians and interdisciplinary team were
faced with compromising their moral duty to administer professional care in accordance with established standards
(Chua & Tham, 2006). A brief review of the literature of Nursing Collection II: Lippincott Nursing Journals (from
Ovid) and CINAHL databases for the past 5 years found no evidence to support best practice for a Jehovah's
Witness who is pregnant and has experienced blunt trauma.
Healthcare providers faced with this situation have sometimes attempted to obtain court orders that would overrule
the patient's decision and result in her submitting to recommended medical treatment. For example, the Illinois
Supreme Court (Illinois v. Brown, 1996) upheld a mother's decision to refuse blood transfusions even though they
were vital for both the mother's and fetus' survival. The Patient's Bill of Rights states that the healthcare providers'
responsibility is to give patients accurate information and that patients must consent to treatment (New York State
Department of Health, 2008). This is consistent with the Federal government's recommendations to create guidelines
that assure healthcare quality and to reaffirm the critical role consumers play in safeguarding their own health,
(United States Department of Health and Human Services, 1999).
Nursing practice is governed by the patient's right to autonomy rather than her religious beliefs (Levy, 1999). The
first item in the American Nurses Association (ANA) Code for Nurses with Interpretative Statements (2001)
addresses respect for human dignity:
"Truth telling and the process of reaching informed choice underlie the exercise of self-determination, which is basic
to respect for person ... Clients have the moral right to determine what will be done with their own person; to be
given accurate information, and all the information necessary for making informed judgments; to be assisted with
weighing the benefits and burdens of options in their treatment; to accept, refuse, or terminate treatment without
coercion; and to be given necessary emotional support" (p. 1).
However, it is difficult to witness death based on a person's decision to forgo care when medical options to sustain
life are available. Treating this type of patient becomes particularly challenging when it involves two lives.
Virtue ethics
To analyze this ethical dilemma, the principles of Western medicine and the religious beliefs of Jehovah's Witnesses
were examined. The questions that surfaced were (a) how would the application of virtue ethics provide insight into
Juana's situation, (b) what were the ethical principles in conflict, and (c) why was it an issue to administer a blood
transfusion to Juana in an emergency situation.
Volbrecht's framework for ethical analysis was utilized to address the clinical dilemma and the questions listed
above. Virtue ethics was the primary theory employed prior to the 17th century. This theory centers on shared
familial and cultural histories and religious traditions and acknowledges the community's ability to identify,
interpret, prioritize, and adjust to moral considerations within a particular context (Volbrecht, 2002). The following
is an exposition of this case according to virtue ethics.
MoreArticles of Interest
• Case Studies in Nursing Ethics
• An ethical dilemma involving a shy-drager patient: a case study
• Dealing with ethical dilemmas: nurses regularly face ethical challenges in...
• Is it an ethical dilemma for sure? - Speaking of Ethics - case study of...
• An ethical dilemma: who should know and who should tell
Virtue ethics focuses on what is morally correct from the patient's viewpoint and centers on the patient's autonomy.
Actions and character are intertwined, and the ability to act morally is contingent on one's moral character and
integrity. Virtue ethics focuses on the context of the situation (Volbrecht, 2002). Ethical analysis of virtue ethics
entails (a) identifying the problem, (b) analyzing context, (c) exploring options, (d) applying the decision process,
and (e) implementing the plan and evaluating results (Volbrecht, 2002).
Identifying the problem
Juana, a 20-year-old Hispanic woman, 32 weeks pregnant, was involved in a car accident. Internal bleeding to the
thoracic or abdominal cavity was suspected. The stakeholders were the woman, her husband, the fetus, and the
interdisciplinary healthcare team. The team thought the best method of treatment for this patient was to administer a
blood transfusion and perform an emergency cesarean section. Both the patient and her husband refused this option
because of their religious beliefs and provided written documentation indicating that the patient would not accept
blood or blood products. The value issues were the physical survival of the woman and her fetus versus the woman's
religious integrity.
Analyzing context
To understand the decision-making process in this case, one must consider the ethical principles of autonomy,
beneficence, nonmaleficence, justice, compassion, and respect. The patient's religious beliefs and how they
influenced her decision must also be taken into consideration. Gardiner (2003) confirms that the ethical principles
mentioned above influence one's choices. In Juana's case, the healthcare team suspected she was experiencing
internal bleeding and that she and the fetus were in physiological distress. Juana's decision to reject the proposed
treatment was based on her stated religious beliefs.
The contextual factors of this case centered on the patient's religious beliefs. The patient stated she would "rather be
embraced in the hollow bosom of Jehovah than to be condemned for all eternity," if she should receive a blood
transfusion. Nurses draw from the code of ethics to reflect upon and understand the person's perspective, and to
honor her wishes. "The nurse provides services with respect for human dignity and the uniqueness of the client,
unrestricted by considerations of social or economic status, personal attributes or the nature of the health problem"
(ANA, 2001, p.1). To respect the patient's decision and honor her dignity, supportive care was provided to the
patient in an effort to save her life, while at the same time respecting her wishes. The ANA Code of Ethics supports
the point of view that healthcare providers should respect patients' wishes and decisions despite their own personal
beliefs (ANA, 2001).
Applying an ethical decision process
Looking through the lens of virtue ethics, the caregivers focused on Juana's autonomy and her right to choose what
she perceived best in spite of the possible outcomes. Juana was a competent, pregnant woman who made informed
decisions not to receive blood transfusions or a caesarean section. Based on virtue ethics, the healthcare providers
respected the patient's autonomy by reflecting on and honoring the decision of the patient and her husband based on
her religious values and beliefs. The healthcare providers also drew on the principle of beneficence, which centers
on promoting the well-being of others. In this case, the well-being was not physiological but spiritually oriented.
The principle of nonmaleficence was also employed by not intentionally inflicting harm on the patient and honoring
her wishes. Violation of a client's deeply held beliefs is a form of doing harm. (Leonard & Plotnikoff, 2000). They
also drew from the principles of veracity and respect, which entail being truthful to the patient and allowing her to
make an informed decision (Volbrecht, 2002). The nursing virtues of compassion, moral courage, and self-reliance
also contribute to an understanding of this situation.
Evaluating results
At the time this clinical situation presented itself there were no specific guidelines in the institution for dealing with
the dilemma presented by this case. However, there are guidelines for Jehovah's Witnesses specifically geared to
early identification and management of gynecological patients. For example, in Australasia, there are specific
guidelines for treating pregnant women that focus on stabilizing the patient by using traditional and new treatment
modalities to meet patient needs, particularly for Jehovah's Witnesses or other patients who decline blood
transfusions (Women's Hospitals Australasia, 2005). For antepartum patients, the guidelines focus on early
identification of Jehovah's Witnesses during prenatal visits, as well as placing these patients on a high risk protocol,
including maintenance of high hemoglobin and hematocrit levels, having advance directives completed, and
establishing affiliations with other hospitals that are well-equipped and staffed to meet these patients' needs
(Women's Hospitals Australasia, 2005). The Hartford Hospital in Connecticut has a similar program and also
performs bloodless procedures on patients who are Jehovah's Witnesses (Miller, 1996).
MoreArticles of Interest
• Case Studies in Nursing Ethics
• An ethical dilemma involving a shy-drager patient: a case study
• Dealing with ethical dilemmas: nurses regularly face ethical challenges in...
• Is it an ethical dilemma for sure? - Speaking of Ethics - case study of...
• An ethical dilemma: who should know and who should tell
As a result of Juana's case being reviewed by the ethics committee post-mortem, a risk-management protocol was
developed requiring patients who refuse blood transfusions to sign a waiver that removes the legal responsibility for
the decision from the hospital and caregivers. To support this type of protocol, the Society for the Advancement of
Blood Management maintains a database of hospitals that provide blood-conserving services in the United States as
well as in Canada, Chile, Korea, and South Africa (Society for the Advancement of Blood Management, 2008).
The problem, however, in an emergency situation is that it may not be possible to get the patient to a participating
hospital. The Watchtower Bible and Tract Society (2004) recommends that advance directives and other legal
papers be in place should an emergency arise. These documents should be easily accessible so that healthcare
providers can honor the patient's directives. In so doing, they will be applying the theory of virtue ethics and,
therefore, respect the patient's wishes (Macklin, 2003). Healthcare providers should practice beneficence and non-
maleficence without imposing their beliefs as to the right thing to do. More explicit and universal guidelines would
benefit both patients and providers when faced with similar ethical dilemmas.
Ethical dilemma and resolution: a case scenario
Joseph K Wells1
Abstract
This article illustrates an ethical dilemma that I faced while treating an 86-year-old woman at her home.
The ethical dilemma was caused due to several factors such as the expectations of the client (client/
consumer rights), organisational expectations (employer, governmental and payer-source regulations)
and my own personal values (one's moral philosophies, perceived social responsibilities, sense of
professional duty) and how they all interact with each other. The case is a classic example of a seemingly
simple yet frequent dilemma encountered by occupational and physical therapists in the United States
serving clients who are covered by Medicare (the government's health insurance) for home health. The
article is aimed at highlighting the various ethical principles involved in clinical decision-making, and it
suggests methods for resolution of ethical dilemmas. Although the article is based against the backdrop
of the US health care system, students and health care practitioners globally can relate to it.
The ethical dilemma in the case discussed below involved whether or not to continue treating a client who
clearly needed occupational therapy services based on medical necessity, yet the payer-source
(Medicare) coverage criteria for services to be delivered at home was questionable. That is, should one
continue to treat the client and uphold the principle of beneficence yet run afoul of the law, or should one
discontinue treating the client to uphold the law but possibly cause harm to the client?
The case scenario
Three years ago, Ms EH, an 86-year-old woman, was referred to me after a debilitating stroke affected
her right side (pre-morbidly her dominant side). Ms EH was admitted under home health after running out
of Medicare allowable days at a skilled nursing facility (SNF). Ms EH needed considerable assistance
with all activities of daily living (ADL) and was primarily wheelchair-bound due to her inability to walk
independently. She lived with her 88-year-old husband Mr. RH, who was also not in the best of health.
Due to financial constraints the couple opted against long-term or assisted living placement in favour of
their trailer home. Ms EH demonstrated good rehabilitation potential and progress with all her home
health services.
One night, approximately three weeks after her return home from the SNF, Mr. RH suffered a massive
myocardial infarction. He was hospitalised and underwent cardiac catheterisation. It indicated diffuse
blockage of multiple vessels and he was deemed a poor candidate for surgery. Subsequent medical
interventions were primarily conservative with a poor prognosis. He was later transferred to a nursing
home. Ms EH obviously was very concerned and depressed about the situation. She was devoted and
would visit Mr. RH for four to six hours everyday at the nursing home after being driven there by her
friends and family. No one could persuade Ms EH to avoid the exertion. She would simply state, " He has
always been there for me. Shouldn't I?"
Soon after her husband's admission to the nursing home, Ms EH began to have difficulty keeping up with
her appointments with me and the other home health providers. Medicare's guidelines for clients to
receive home health under Part-A Insurance Plan require them to meet certain "homebound" criteria. The
Center for Medicare and Medicaid Services (CMS), formerly called the Health Care Financing Agency
(HCFA), describing homebound status states that, "there exists a normal inability to leave home and,
consequently, leaving home would require a considerable and taxing effort. If the patient does in fact
leave the home, the patient may nevertheless be considered homebound if the absences from the home
are infrequent or for periods of relatively short duration, or are attributable to the need to receive health
care treatment..." (1).
Ethical principles at risk
As per organisational requirements (Medicare's as the regulatory and the home health agency's as the
regulated body), Ms EH was clearly homebound based upon her physical limitations; however, her daily
absences did not exactly fit the "infrequent" or "short-duration" requirements for Medicare coverage. Much
of the ethical confusion was also caused due to the inability of the coverage guideline to exactly quantify
the terms "infrequent" and "short duration" and leaving it for further interpretations. The client's
expectation and what could be perceived as her right to receive health care at her home based upon her
medical necessity (client/consumer rights), and my moral duty to provide treatments and my obligation
toward her well-being (my personal beliefs) were thus in conflict with the organisational interpretation/
procedures based on regulations that set criteria for services (rules of practice, possible legal issues
involved).
The various ethical principles at risk were as follows:
Autonomy: The client's right based upon her self-determination to receive occupational therapy services
at home, and my own professional autonomy to decide where the client should receive the services were
under question. As stated by Shanawani and Lowe, our professional schooling prepares us with,
"guidelines, rules and regulations, and legal judgments relevant to our decisions about where to treat
patients...(based on) medical variables of the patient's health... and the anticipated care needs of the
patient. Nowhere do non-medical [italics added] variables of patient financial resources, insurance
reimbursement, and patient and family preference play an explicit role in those decisions" (2).
Veracity: My professional obligation to speak and act truthfully regarding the client's inability to follow the
homebound criteria to continue receiving services at home interfered with my respect for the client's
autonomy.
Justice: While I felt a strong sense of duty to care for my client, I realised that the client did not clearly
satisfy all Medicare coverage criteria (3).
Fidelity: I viewed this principle as my ability to uphold my commitments to all parties involved, such as the
client, my organisation, and the government (via Medicare regulations) and my self as a moral agent.
Beneficence: The client strongly believed that she needed home occupational therapy services and that
she was truly benefiting from these. In my professional judgement, too, the client certainly could benefit
with continued services. However, this beneficence seemed to conflict with the legal and ethical aspects
of delivering services.
Other ethical principles caused me to introspect on what kinds of consequences were good or valuable. I
hoped that I was able to be truthful, moral and of benefit to my client through my actions. I also
contemplated on what would be a virtuous route to meet the care needs of my client, act in her best
interests and cause her maximum gains.
My dilemma forced me to explore the meta-ethical bases of these principles, since several principles were
at risk or were conflicting. Do I resolve my ethics based on reason as taught by Immanuel Kant or do I
base it on sympathy as proposed by Hume? Do my professional duties conflict with my personal religious
beliefs to do good unto others? Will my social contract as a therapist be broken if I discharged my client
from my care since she did not meet the Medicare (legal) requirements (4)?
The theories of ethics applicable to my dilemma
My dilemma involved various ethical principles that are based upon different ethical theories. My case, as
with most occurrences in health care, had elements of all major ethical theories. The theories influencing
my decision process were:
(a) Teleology, in my pursuit to benefit my client (consequentialism); (b) Virtue-based ethics to strive for my
client to receive the care and goodness that I or any human may hope for; (c) Value-based ethics to be
truthful and good as a person and professional and cause happiness for my client, and (d) Ethics of care
due to the therapist-client relationship I had developed and my concern for my client's care. However, I
believe that my dilemma and its resolution were derived from and best explained by the theory of
deontology.
Deontologism focuses on the very action and its process, and the moral rules and principles involved with
the act versus the consequences of the action itself. It emphasises that one must act in accordance with
rules and principles of ethics such as respect for autonomy, non-malfeasance, beneficence, justice,
fidelity, veracity and avoidance of killing (5). That is, it focuses on acting morally based on one's duty
versus basing one's action on the results that it causes.
The resolution and the methods used
After detailed discussions with the client and her family, I discontinued home-based occupational therapy
services and referred the client for outpatient rehabilitation.
Jonsen, Seigler, and Winslade (1998), Purtillo (1993) and, Trompetter, Hansen, and Kyler-Hutchinson
(1998) have all proposed several methods or processing tools to analyse ethical dilemmas (6,7,8).
Kornblau and Starling (1999) also proposed a framework for ethical decision-making. It was called the
CELIBATE method (an acronym for 'Clinical Ethics and Legal Issues Bait All Therapists Equally'). The
acronym acts as a cue for the user of the framework with each letter representing an aspect for analysis
(for example: C for clinical situation, E for ethical issues, L for legal issues, I for information, B for
brainstorming action steps, A for analysing action steps, T for taking the action and E for evaluating the
results) (5).
In the course of analysing and applying a methodology to resolve my ethical dilemma, I charted my
ethical course via a framework. Based on this model, we can divide the entire ethical process when faced
by a dilemma into three phases, namely the ethical encounter, the ethical loading and ethical unloading.
The ethical encounter: This phase as applied to my case has been discussed under the section titled
'The case scenario'. The parties involved are the client, my self, the home health agency that employs my
services, the CMS, the State Occupational Therapy Board due to its judiciary powers over the practice of
occupational therapy, the American Occupational Therapy Association (AOTA) as it regulates the
profession and sets codes of ethics (9), the scope (10) and standards of practice (11); the client's family,
and the community as a whole based upon the potential impact of my services (or the lack of services) on
my client's health and well-being. In the encounter phase, we face all the interacting human and/or
organisational components of the ethical issue.
The ethical loading: In this phase we analyse the various issues facing us. Whether the law has been
violated, or is at risk, or was there just an ethical problem with no legal implications? My dilemma involves
whether or not to continue services although there is a medical necessity, but the client may not
necessarily meet the coverage criteria for payment. In this case, one may clearly recognise both ethical
and legal issues. Legal issues are based upon Medicare and state practice acts governing the profession
as well as the AOTA code of ethics (9) and standards of practice (11). This phase bears the load to
introspect and discover legal and ethical violations or risks and analyse methods and the future course of
action. We have discussed the ethical issues pertaining to my client in the section titled 'Ethical principles
at risk'. In this case, we determined that the theory of deontology best guided our course of resolution.
The ethical unloading: Based upon my realisation and analysis of the ethical-legal aspects involved, I
mainly geared my actions toward ethical resolution since there were no legal violations as yet and no
separate legal actions were warranted other than those implied by ethical actions. My ethical actions were
aimed at mainly upholding deontological principles by following my professional duty as perceived under
Medicare and state practice acts, and by not interfering with the regulation with my own interpretation and
attempt to liberalise it. I chose to rather use the regulation in its most restrictive form in order to ensure
that no confusing elements could cause further dilemmas. This upheld the cause of justice, veracity, and
my fidelity toward the law that governs my professional practice.
With the ability to visit her husband at the nursing home at will, the client's autonomy was upheld as well.
Ms EH was also counselled on her options to receive services under Medicare Part-B plan at an
outpatient rehabilitation clinic or other qualifying health care facilities. Fortunately, the facility where her
spouse was admitted agreed to also treat her as an outpatient. The client found this acceptable and
feasible as well.
My course of action also ensured non- malfeasance and beneficence by ensuring continuity of services
desired and needed by the client in an environment that was acceptable to her. It is in this phase where I
"unloaded" my ethical burden through actions that I chose based upon my prior experience, training
and/or conscience.
As with any clinical case, we may view the "ethical encounter" as a phase where we focus on the
demographics and situation at hand. The "ethical loading" phase mainly deals with recognising the ethical
and legal issues involved (like the diagnostic process), and investigating and selecting the best course of
action (formulating a plan for intervention). Finally, the "ethical unloading" phase involves the application
of actions/ interventions with the aim of resolving an issue (outcome). Therefore, this phase must also
reflect on the effectiveness of the actions/ interventions in meeting the interests of all parties in the
situation.
Commentary
In my opinion, this case presents an ethical conflict frequently faced by home health care providers,
where they strive to best serve their clients' needs while navigating through complex financial coverage
issues. Emanuel, a physician-philosopher, and Fuchs, an economist, propose the coupling of much-
valued freedom of choice with universal health coverage for Americans (12).
The scope of this article was not to address the efficacy of the American health policy but to recognise an
everyday dilemma faced in the health care arena. Through experience and common knowledge, we
know that health care professionals face similar ethical issues globally. Advances in client education and
awareness have led to increased sensitivity and applicability of client rights and autonomy. This has also
led to several legal developments and awareness of biomedical-ethics internationally.
A clinician, more than ever before, must be prepared to not only address the clinical needs of his/ her
clients but also base this on socio-cultural and ethical constructs. A sound knowledge of ethical theories
and principles helps to guide a clinician's actions. As Abraham Lincoln once stated, "Let us have faith that
right makes might, and in that faith, let us, to the end, dare to do our duty as we understand it (13)."
References
1. Center for Medicare and Medicaid Services [web page on the Internet]. Home health manual
(Rev. 302): Chapter II-Coverage of services. Baltimore (MD): Center for Medicare and Medicaid
Services; c2003- [cited 2005 July 24]. Available
from: http://www.cMshhs.gov/manuals/11_hha/hh200.asp
2. Shanawani H, Lowe KN. Is Greenacres (SNF) the place to be? Virtual Mentor [serial on the
Internet]. 2005 [cited 2005 July 24]; 7 (7). Available from: http://www.ama-
assn.org/ama/pub/category/3040.html
3. Prosser WL. Law of torts. St Paul (MN): West Publishing Co; 1971.
4. Veatch RM. The basics of bioethics. 2nd ed. Upper Saddle River (NJ): Prentice Hall; 2000.
5. Kornblau BL, Starling SP. Ethics in rehabilitation: aclinical perspective. Thorafare (NJ): Slack Inc;
1999. p 53-4.
6. Jonsen AR, Seigler M, Winslade WJ. Clinical ethics. New York: McGraw Hill; 1998.
7. Purtillo R. Ethical dimensions in the health professions. Philadelphia, PA: WB Saunders; 1993.
8. Trompetter L, Hansen R, Kyler- Hutchison P. Reference guide to the occupational therapy code
of ethics. Bethesda (MD): American Occupational Therapy Association; 1998.
9. American Occupational Therapy Association [web page on Internet]. Occupational therapy codes
of ethics. Bethesda (MD): The Association; c2005- [cited 2005 July 25]. Available
from:http://www.aota.org/general/docs/ethicscode05.pdf
10. American Occupational Therapy Association [web page on Internet]. Scope of practice. Bethesda
(MD): The Association; c2004- [cited 2005 July 25]. Available
from:http://www.aota.org/members/area2/docs/scope.pdf
11. American Occupational Therapy Association [web page on the Internet]. Standards of practice for
occupational therapy. Bethesda (MD): The Association; c2005- [cited 2005 July 25]. Available
from:http://www.aota.org/members/area2/docs/otsp05.pdf
12. Emanuel EJ, Fuchs VR. Health care vouchers�"a proposal for universal change. N Engl J
Med. 2005; 352: 1255-1260.
13. Quotable Online [web page on the Internet]. Quotes by subject: Duty quotes. Web Publishing
Group, LLC; c2004-[ cited 2005, July 25]. Available
from: http://www.quotableonline.com/quotesubjectss.php?subject=Duty&page=2
Ethical Dilemma in Today's Business
Global interdependence is a compelling dimension of the global business environment, creating
demands on international managers to take a positive stance on issues of ethical behavior, social
responsibility, economic development in host countries, and environmental protection around the
world. However, there were still several large multinational companies indulging in ethically
questionable practices. If MNCs behave unethically, it soon comes to the notice of the public and
the company’s image is tainted. Multinationals are often worse off for having behaved
unethically in the interest of short term gains, as the bad publicity generated by unethical
practices leads to far greater losses in the long run.
In the challenge of modern society, manager or worker often encounters a situation than
challenges one’s ethical beliefs and standards. Managing across border increasingly includes
difficult ethical dilemmas. It is less clear where to draw the line between ethical behavior and the
corporation’s other concerns, or between the conflicting expectations of ethical behavior among
different countries. The paper aims to (1) discuss current ethical dilemmas in global
environmental ethics, (2) examine how multinational would address conflicting norms and
expectations by illustrating one case study of ethical dilemma and its resolution.
Nestlé’s Corporate Crimes
1.0 Nestlé’s ethical dilemmas
1.1. Unethical marketing practices
Infant formula
In 1977, Nestle got embroiled in a controversy, when it was criticized for using unethical
marketing practices endangering consumer health to promote its infant formula in developing
nation. A number of aid agencies called for the boycott of Nestle products and this protest
continued right into the 1980s, when Nestle agreed to adopt the infant formula marketing code
laid down by the World Health Organization and UNICEF. Although Nestle had a charter on
infant formula, the company is usually violated the principles laid down in it (Refer to
reference3).
Genetically Modified Foods
Nestle was criticized for using genetically modified (GM)[1] ingredients in its food products, and
was accused of dumping products rejected in Europe in developing Asian countries where the
laws on GM products were either absent or less stringent.
For Kant, the company’s decision makers would have to be willing to advocate marketing the
product even if they were themselves in the position of uniformed consumers. Therefore,
providing unsafe products standard and ill-informed consumers by Nestle is absolutely wrong.
1.2. Overcharged prices
Nestle launched bottled water, called “Pure Life” in some Asian countries
like Pakistan andIndia (in 1998 and 2001 respectively). Nestle introduced bottled water, which
provided safe clean water but priced it so high that it was unaffordable for the lower income
groups. It turned water into a luxury by pricing it around $ 0.4 (in Pakistan) for a one liter bottle.
According to utilitarianism, ethical action is evaluated by looking at its consequences, weighing
the good effects against the bad effects on all the people affect by it (Shaw & Barry, 2004). Most
developing countries laced basic drinking water facilities. A very high water price was charged
by Nestle limiting a number of people to buy it. Nestlé’s action produces the worse for the
greatest number of South Asian because people could not afford for water which is basic human
needs and is sporadic and contaminated in south Asiacountries.
1.3. Unfair labor practices
Nestle was one of the biggest purchasers of cocoa from Ivory Coast, a country in West Africa.
UNICEF studies and International Labor Organization (2002) revealed that the workers on these
plantation lived and worked in poor conditions. They were paid minimal wages and exploited by
the land-owners. Most of the workers had been trafficked by bought and sold, making them
practically slave labor. Nestle purchased cocoa from these farms despite its awareness of the
conditions of the laborers, thus making it a party to their exploitation.
Child labor was also employed on the plantation. UNICEF and The International Institute of
Tropical Agriculture (IITA) studies (2002) revealed that over 200,000 children were shipped to
Ivory Coast and other cocoa producing countries in Western Africa from neighboring countries
like Mali and Burkina Faso, to work on the plantations, especially during the harvesting of cocoa
or coffee beans.
Another unfair labor practice was occurred in Thailand. When a group of 13 workers, wording in
a sub-contracting facility of Nestle in Thailand, organized themselves to form a union, Nestle
immediately cut the number of orders to that company and asked the company to put the
unionized workers on indefinite leave with half pay. The workers were force to quit because of
their lowered pay (Manager 2001). In doing so, Nestle had clearly denied these workers their
right to organize themselves to better their interests.
1.2. Applying De George’s principles
International business ethics refers to the conduct of MNCs in their relationships to all
individuals and entities with whom they come into contact (Daft, 2002). Ethical behavior is
judged and based largely on the cultural value system and the generally accepted ways of doing
business in each country or society. MNC Manager must decide whether to base their ethical
standards on those of the host country or those of the home country and whether these different
standards can be reconciled (Donalson, 1996).
1.2.1. Do no harm
Thompson & Stickerland, (2003, p. 65) asserts that “a company has ethical duties to owners,
employees, customers, suppliers, the communities where it operates, and the public at
large.” The norm of doing no harm requires Nestlé’s management to look beyond its own
interests (i.e., cheap cocoa, and high market-share). Unethical marketing of infant formula and
GM foods in developing countries are example of doing harm knowingly and willingly and of
benefiting from the lack of legal restraints to the detriment of the eventual consumers. If business
follow Kant’s rule, it will provide a quality and safe product to its entire market. Nestle decide to
sell unsafe (GM) foods even it knows that the product is unsafe. In addition, Nestlé’s marketing
strategy in developing countries was to distribute free samples to nursing mothers, thus getting
the baby used to the formula very early in order to get a hold on its captive market. Unethically,
Nestlé promoted the use of infant milk formula as a substitute for mother’s milk. This unethical
manner causes widespread infant malnutrition and susceptibility to infection, which could even
lead to infant death. Following this norm, Nestle should preserve the safety and health of
consumers by disclosure of appropriate information, proper labeling and accurate advertising.
Workers on cocoa production from Ivory cost were paid below minimal wages and were
practiced as slave labor. Despite its awareness of the conditions of the labors, Nestle continued
purchased of cocoa from these suppliers. The company must pressurize its suppliers to change
because it is in a position of major buyer. Regarding to Nestlé’s inThailand, the company should
respect the right of employees to organize for the purpose of collective bargaining. Nestle had
better prohibit retaliation to their employees, though disciplinary action, or an anti-harassment
policy. In addition to Anti- harassment, companies need to develop policies and procedures to
prevent retaliation against individual who file complaints of harassment or discrimination or who
participate in their investigation (Zimmerman, 2002).
1.2.2. Do more good
In Ivory Coast, Children worked in hazardous conditions using machetes and spraying pesticides
and insecticides without the necessary protective equipments. Such exploitation involves in
significant Nestlé’s profit since the labors received only a very small proportion of the price paid
for the Nestle product by the final consumer. According to the norm of doing more good than
harm to host country, Nestle must stop buying cocoa from South Africa, which is under
apartheid and uses child labor in hazardous working condition. For a utilitarian, however, these
are considerations that can be balanced against other considerations, such as the benefit to others.
On the other side of the balance are factors like corporate reputation (Orts, 1995). These factors
can make corporate altruism worthwhile in the long run, even at the short-run expense of the
stockholders. Nestle should demonstrate its ethical commitment through philanthropic
contribution and use of its expertise and resources on numerous social problem in host countries.
Importantly, Nestle should integrate social and ethical issue in strategic process (see figure4).
Along with an investment appraisal, such planning should include an environmental impact
assessment. According to Whetton & Cameron (2005) leadership is the key success for
organizational change as well as the key to aligning organizational systems and follower
behaviors around a new organizational vision. Ethical leadership practices are necessary
prerequisite for organizational effectiveness (Ausguien, 2001). Therefore, Nestle top
management must train to be ethical leadership (see Recommendation action in appendix3).
Figure4: Integrating social and ethical issues in the strategic management process
Social & Ethical Issues
Environmental Analysis
Establishing Organizational Direction
Strategic
Implementation
Strategic Formulation
Strategic
Control
Source: Adapted from Thompson & Stickerland (2003, p.7)
To upgrade company’s ethics, Nestle must impose codes of conduct that treating other person
with respect and should provide leadership’s ethical training as leaderships are key person to
make a strategic-decision. Examples of codes of conduct include do not use child or forced labor,
provide a safe working environment, and respect worker rights to unionize (Refer to figure2).
Corporate moral excellence can be alternative to develop Nestlé’s ethical culture. For a corporate
to be morally excellent, it must develop and act out of a moral corporate culture (Hoffman,
1994). In a situation with intolerance arise, manager should be guided by precise statements that
spell out the behavior and operating practices that Nestlé’s demand. Nestle must be careful when
placing a foreign manager in a country whose values are incongruent with his own because this
could lead to conflict with local managers, governmental bodies, customers and suppliers.
1.2.3. Respect the human rights of their employees
Doing good business and being a good employer is pivotal and important guidelines in doing
today’s multinationals. In fact, ethical business must respect for human dignity, and protect the
fundamental rights of people. According to Aristotelian, equal should be treated equally and
unequal unequally (Hirschman, 2001). This infers that individuals should be treated the same,
unless they differ in ways that are relevant to the situation in which they are involved. If labors
work the same jobs, they should be paid the same wage. If Nestle pays its labors less than other
companies, then Nestle has an injustice in remuneration system. Violating human rights is
immoral practices due to Kant’s principle. This indicates that Nestle exploited and treated others
as means rather than as ends, as thing rather than as person. Not only does Nestle (exploiter) fail
to do its duty to others, but also fails to do this duty to itself; Nestle make itself into an object.
1.2.4. Respect local regulations
MNCs are subject to the laws, regulations, and jurisdiction of the countries in which they operate
(OECD, 2004). Nestle must not resist against law that protect the country’s workers or
consumers, even if such laws make operating in these countries less profitable. It is evidence that
Nestle did not respect for domestic rules and regulation. Nestle broke Thai law bys paying
workers less than minimum wage and cut them off. For consumer safety, Nestle did not respect
the laws and regulations of the countries in which they operate with regard to consumer
protection. In China, there is a regulation of GM food, which required that all products which
were contained GM ingredients, be labeled explicitly. Despite consist of GM ingredients, Nestle
products were not labeled. Indeed, it could not unilaterally continue with its double standard
practice and ignore the concerns and demands of the general public in Asia.
[1] Genetically modified foods are lab-crated grains, vegetables, fruits and other primary foods. Their use has been
somewhat controversial. Some people are concerned about the consequences to their health of the use of these
products. European countries require all GM foods to be clearly labeled as such; however, in countries Canada and
the US, labeling is optional.
Ethical Dilemmas in Business
There are many areas where ethical dilemmas arise. Here are five categories of common
ethical dilemmas in business:
1. Human resource issues
2. Employee safety issues
3. Conflicts of interest
4. Customer confidence
5. Use of corporate resources
We shall discuss ethical dilemmas related to human resource issues here.
Human resource issues
Human is the most important resource to an organization. Issues associated with human
resources occur as a result of employees working together. These issues are by far the
largest category of ethical dilemmas in business.
The four main types of human resource issues are as follows:
• Hiring and Termination Issues
Recruitment or hiring process is the first step in selecting human resource into an
organization, and will significantly influence the successful performance of the organization.
Ethics plays a very important role during the recruitment of new employees. Law and
regulations dictate that we have to be ethical in hiring. However, ethical hiring practice goes
beyond them as well. It has been widely reported by many researchers that ethical hiring
practices actually result in better employees being recruited.
It is therefore important that sound ethical rules are followed when hiring a new employee.
It is of vital importance that candidates are to be selected based on merits. Applicants are
to be hired based purely on merits such as knowledge, skills, and ability in accordance to the
needs of the organization.
If a company provides any special considerations, for example affirmative action, where
certain groups are given special considerations, these considerations should be well stated
in the company's policy statement. In any case, any preferential treatment should be one
that is legally allowed.
While preferential treatments to certain specific group may be allowed, there should be no
discrimination to people from any other group due to race, religion, gender, marital or even
pregnancy status.
Consistency and objectivity during the recruitment process are very important. Criteria,
including any changes in the criteria, used for evaluating candidates should be stated and
explained to order to avoid unnecessary claim of biasness in the recruitment process.
Objective evaluation results in the best employees being recruited while consistency ensures
high morale among employees.
When we recruit new employees, we should tell the applicants about the true state of the
organization. We should not mislead the applicants. In particular, the applicants should be
told all pertinent information, including those information that are not publicly known but that
will materially affect the new employee's future employment prospect with the organization.
We can learn from the case involving Phil McConkey. Phil McConkey was recruited but he was
not aware that the company was in the process of being taken over by another entity. One
year after joining the company he lost his job with he new company. He sued the company
for with-holding important information from me during the recruitment process. He won the
case and was awarded $10 million.
We should never place misleading job advertisement in order to get applications if we are
offering a job contract different from what we advertised for. For instance, if we want to
engage independent contractors instead of normal salaried employment. The reason why
we choose to engage independent contractors is that we do not have to be burdened with
high salary cost for employees that are not competent, but we are willing to compensate
employees according to performance. We should always state clearly our terms of
employment. In any case, we do not want to be accused of any job scam.
We have to be extra careful when we are recruiting employees from organizations that have
material dealing with us include our suppliers, customers and competitors. If we are not
careful ethical issues very damaging to us can arise.
When we employ somebody from our suppliers, the suppliers may feel that we have
unethically poached their good employee. After all, it is through the working relationship we
have with the suppliers that we can to know the quality of this employee.
When we employ somebody from our customers we can be accused of returning favor to that
person. This rule applies especially when employing a former senior government employee
that has an influence on the awards of contracts to an organization like yours. The case of
Ms. Darleen Druyun at the Department of Defense and Mr. Michael Sears at Boeing is a good
illustration of the importance of such a rule. In this case, employment favor was apparently
granted by Boeing in exchange for favorable consideration for the awards of contracts by
Department of Defense. Also, be careful not to employ former government employees for the
purpose of lobbying for contracts from their previous government departments. At least, do
not do so within the first two years of the employee leaving the government service.
It is also not very wise to employ somebody from our competitors because we can be
accused of stealing trade secrets from our competitors. If that employee can pass on his
previous employer's secrets unethically, what is there to sop him from passing your trade
secrets to others?
Even though it may not be considered as unethical by some employers, as a matter of
courtesy and good public relationship to inform an unsuccessful applicant.
When an employee is asked to leave, it is also of vital importance that it is handled with
fairness and care. If it is a case of poor performance or disciplines, the employee has to be
given prior warning (unless it is violation of a well stated policy or is of a very serious nature)
and fair hearing. In any case, do not hurt the dignity of the employee and offer to provide
the necessary assistance where appropriate.
Before an employee leave for any reason, provide him/her with an opportunity to provide
feedback on the overall state of the organization by conducting exit interviews.
• Discrimination is the unfair or preferential treatment of a person on the basis of one or
more uncontrollable characteristics, including race, gender, age, color, religion, or national
origin, as well as handicapped or pregnancy status.
Discrimination against others in the workplace can impair your ability to perform your job
according to company expectations.
In most countries, there are laws that protect potential and current employees from
discrimination based on age, race, color, national origin, religion, and gender, as well as
pregnancy or handicapped status.
• Performance Appraisals are conducted to evaluate an employee’s performance over a set
period of time.
When evaluating subordinates, one has to remain consistent and objective. Consistency is
even more important when evaluating an existing employee than a prospective employee.
Consistency requires that you treat every employee's misbehaviour the same way. For
example, it would be wrong to punish one employee's tardiness while leaving another
employee's tardiness unchecked.
In order to maintain objectivity, the company’s standardized evaluation forms should be
used. In this way, uniform criteria can be used for the appraisal of all employees under you.
Also, all employees in the company are evaluated based on the same criteria.
Constant feedback and communication between you and your subordinates is necessary to
facilitate a positive and productive working relationship. Don’t wait until periodic performance
evaluations to express your observations and suggestions. In fact, it is unethical to base
salary adjustments upon performance problems that have not been brought to the employee’
s attention.
For employees being evaluated, honesty and acceptance of responsibility for performance
problems are important ethical considerations.
• Disciplinary issues
Disciplining employees is one of the most difficult parts of a manager’s job. Nevertheless, it
is vital to the growth and overall success of the organization.
Disciplining employees both ensures productivity and sets standards for the future.
Discipline should occur immediately after a problem has occurred. It is imperative that the
disciplinary actions remain consistent for all employees.
A serious disciplinary issue is sexual harassment where female employees (less so for male
employees) are subjected to an unwanted sexual behavior that creates an intimidating or
hostile work environment. This includes unwelcome sexual advances, requests for sexual
favors, and other verbal or physical conduct of a sexual nature. This conduct is not only
unethical, but illegal as well.
Research Paper help
https://www.homeworkping.com/

Más contenido relacionado

La actualidad más candente

For delivery fdar charting
For delivery fdar chartingFor delivery fdar charting
For delivery fdar chartingLyca Mae
 
Ethical dilemmas powerpoint3
Ethical dilemmas powerpoint3Ethical dilemmas powerpoint3
Ethical dilemmas powerpoint3Iris Wilkins
 
Patricia Benner (Novice to Expert Theory)
Patricia Benner (Novice to Expert Theory)Patricia Benner (Novice to Expert Theory)
Patricia Benner (Novice to Expert Theory)Mary Ann Adiong
 
Philippine Nursing Theorist Sister letty G. kuan
Philippine Nursing Theorist Sister letty G. kuanPhilippine Nursing Theorist Sister letty G. kuan
Philippine Nursing Theorist Sister letty G. kuanMaita Virgini Tan
 
CMO 30 S.2001/CMO14 S. 2009/CMO 15 S 2017 COMPARISON
CMO 30 S.2001/CMO14 S. 2009/CMO 15 S 2017 COMPARISONCMO 30 S.2001/CMO14 S. 2009/CMO 15 S 2017 COMPARISON
CMO 30 S.2001/CMO14 S. 2009/CMO 15 S 2017 COMPARISONDabylinBersonda
 
Nursing Leadership & Management
Nursing Leadership & ManagementNursing Leadership & Management
Nursing Leadership & ManagementJofred Martinez
 
Nursing Theories in the context of ASSESSMENT (2)
Nursing Theories in the context of ASSESSMENT (2)Nursing Theories in the context of ASSESSMENT (2)
Nursing Theories in the context of ASSESSMENT (2)May Vallerie Sarmiento
 
THEORETICAL FOUNDATIONS OF NURSING.pdf
THEORETICAL FOUNDATIONS OF NURSING.pdfTHEORETICAL FOUNDATIONS OF NURSING.pdf
THEORETICAL FOUNDATIONS OF NURSING.pdfHaraLakambini
 
Application of nursing theories
Application of nursing theories Application of nursing theories
Application of nursing theories Arun Madanan
 
Analysis and Utilization of Relevant Data in Nursing Process
Analysis and Utilization of Relevant Data in Nursing ProcessAnalysis and Utilization of Relevant Data in Nursing Process
Analysis and Utilization of Relevant Data in Nursing Process91varsha
 
Culturally competent nursing care - To the Filipino Patient
Culturally competent nursing care - To the Filipino PatientCulturally competent nursing care - To the Filipino Patient
Culturally competent nursing care - To the Filipino Patientmelijaje87
 
Transcultural Syllabus.docx
Transcultural Syllabus.docxTranscultural Syllabus.docx
Transcultural Syllabus.docxRegie De Jesus
 
Movie Character Health Assessment "My Sisiter's Keeper"
Movie Character Health Assessment "My Sisiter's Keeper"Movie Character Health Assessment "My Sisiter's Keeper"
Movie Character Health Assessment "My Sisiter's Keeper"vinishamahesh
 
Medical ethics
Medical ethicsMedical ethics
Medical ethicsAmarBhutts
 
Impaired Gas Exchange Nursing Care Plan
Impaired Gas Exchange  Nursing Care PlanImpaired Gas Exchange  Nursing Care Plan
Impaired Gas Exchange Nursing Care PlanNursing for Life
 
The Medical Home Model: Patient Centered Care
The Medical Home Model: Patient Centered CareThe Medical Home Model: Patient Centered Care
The Medical Home Model: Patient Centered CareGroup Health Cooperative
 
Application of theories, models and conceptual frameworks into family health ...
Application of theories, models and conceptual frameworks into family health ...Application of theories, models and conceptual frameworks into family health ...
Application of theories, models and conceptual frameworks into family health ...Arun Madanan
 
Lecture 9&10 patients rights (13.3.2017)
Lecture 9&10  patients rights (13.3.2017)Lecture 9&10  patients rights (13.3.2017)
Lecture 9&10 patients rights (13.3.2017)Dr Ghaiath Hussein
 

La actualidad más candente (20)

For delivery fdar charting
For delivery fdar chartingFor delivery fdar charting
For delivery fdar charting
 
Ethical dilemmas powerpoint3
Ethical dilemmas powerpoint3Ethical dilemmas powerpoint3
Ethical dilemmas powerpoint3
 
Patricia Benner (Novice to Expert Theory)
Patricia Benner (Novice to Expert Theory)Patricia Benner (Novice to Expert Theory)
Patricia Benner (Novice to Expert Theory)
 
Philippine Nursing Theorist Sister letty G. kuan
Philippine Nursing Theorist Sister letty G. kuanPhilippine Nursing Theorist Sister letty G. kuan
Philippine Nursing Theorist Sister letty G. kuan
 
CMO 30 S.2001/CMO14 S. 2009/CMO 15 S 2017 COMPARISON
CMO 30 S.2001/CMO14 S. 2009/CMO 15 S 2017 COMPARISONCMO 30 S.2001/CMO14 S. 2009/CMO 15 S 2017 COMPARISON
CMO 30 S.2001/CMO14 S. 2009/CMO 15 S 2017 COMPARISON
 
Nursing Leadership & Management
Nursing Leadership & ManagementNursing Leadership & Management
Nursing Leadership & Management
 
Nursing Theories in the context of ASSESSMENT (2)
Nursing Theories in the context of ASSESSMENT (2)Nursing Theories in the context of ASSESSMENT (2)
Nursing Theories in the context of ASSESSMENT (2)
 
THEORETICAL FOUNDATIONS OF NURSING.pdf
THEORETICAL FOUNDATIONS OF NURSING.pdfTHEORETICAL FOUNDATIONS OF NURSING.pdf
THEORETICAL FOUNDATIONS OF NURSING.pdf
 
Republic act no 9173
Republic act no 9173Republic act no 9173
Republic act no 9173
 
Application of nursing theories
Application of nursing theories Application of nursing theories
Application of nursing theories
 
Analysis and Utilization of Relevant Data in Nursing Process
Analysis and Utilization of Relevant Data in Nursing ProcessAnalysis and Utilization of Relevant Data in Nursing Process
Analysis and Utilization of Relevant Data in Nursing Process
 
NCM 100 *LECTURES*
NCM 100  *LECTURES*NCM 100  *LECTURES*
NCM 100 *LECTURES*
 
Culturally competent nursing care - To the Filipino Patient
Culturally competent nursing care - To the Filipino PatientCulturally competent nursing care - To the Filipino Patient
Culturally competent nursing care - To the Filipino Patient
 
Transcultural Syllabus.docx
Transcultural Syllabus.docxTranscultural Syllabus.docx
Transcultural Syllabus.docx
 
Movie Character Health Assessment "My Sisiter's Keeper"
Movie Character Health Assessment "My Sisiter's Keeper"Movie Character Health Assessment "My Sisiter's Keeper"
Movie Character Health Assessment "My Sisiter's Keeper"
 
Medical ethics
Medical ethicsMedical ethics
Medical ethics
 
Impaired Gas Exchange Nursing Care Plan
Impaired Gas Exchange  Nursing Care PlanImpaired Gas Exchange  Nursing Care Plan
Impaired Gas Exchange Nursing Care Plan
 
The Medical Home Model: Patient Centered Care
The Medical Home Model: Patient Centered CareThe Medical Home Model: Patient Centered Care
The Medical Home Model: Patient Centered Care
 
Application of theories, models and conceptual frameworks into family health ...
Application of theories, models and conceptual frameworks into family health ...Application of theories, models and conceptual frameworks into family health ...
Application of theories, models and conceptual frameworks into family health ...
 
Lecture 9&10 patients rights (13.3.2017)
Lecture 9&10  patients rights (13.3.2017)Lecture 9&10  patients rights (13.3.2017)
Lecture 9&10 patients rights (13.3.2017)
 

Similar a 59058785 case-study

Medical Ethics In Prisoners Of War
Medical Ethics In Prisoners Of WarMedical Ethics In Prisoners Of War
Medical Ethics In Prisoners Of WarLindsey Campbell
 
Persuasive Essay On Right To Die
Persuasive Essay On Right To DiePersuasive Essay On Right To Die
Persuasive Essay On Right To DieFelicia Barker
 
PHI 413V Grand Canyon University Week 4 Personal Experiences Learning.pdf
PHI 413V Grand Canyon University Week 4 Personal Experiences Learning.pdfPHI 413V Grand Canyon University Week 4 Personal Experiences Learning.pdf
PHI 413V Grand Canyon University Week 4 Personal Experiences Learning.pdfsdfghj21
 
The Slippery Slope Of Euthanasia
The Slippery Slope Of EuthanasiaThe Slippery Slope Of Euthanasia
The Slippery Slope Of EuthanasiaTeisha Hicks
 
Ethical And Professional Implications Essay
Ethical And Professional Implications EssayEthical And Professional Implications Essay
Ethical And Professional Implications EssayHeather Dionne
 
Carlos Albizu University Week 2 Research Methods in Healthcare Management.docx
Carlos Albizu University Week 2 Research Methods in Healthcare Management.docxCarlos Albizu University Week 2 Research Methods in Healthcare Management.docx
Carlos Albizu University Week 2 Research Methods in Healthcare Management.docxstirlingvwriters
 
The Mental Capacity Act 2005
The Mental Capacity Act 2005The Mental Capacity Act 2005
The Mental Capacity Act 2005Sabine Perez
 
Personal Experiences Learning Discussion.pdf
Personal Experiences Learning Discussion.pdfPersonal Experiences Learning Discussion.pdf
Personal Experiences Learning Discussion.pdfsdfghj21
 
Essay On Advance Directives
Essay On Advance DirectivesEssay On Advance Directives
Essay On Advance DirectivesLela Retzlaff
 
Bioethics intoduction
Bioethics intoductionBioethics intoduction
Bioethics intoductionazzip khan
 
For Euthanasia Persuasive Essay
For Euthanasia Persuasive EssayFor Euthanasia Persuasive Essay
For Euthanasia Persuasive EssayCasey Hudson
 
CHAPTER18End-of-Life Issues© sfam_photoShutterstockWhen
CHAPTER18End-of-Life Issues© sfam_photoShutterstockWhenCHAPTER18End-of-Life Issues© sfam_photoShutterstockWhen
CHAPTER18End-of-Life Issues© sfam_photoShutterstockWhenJinElias52
 
Ethical Perspectives on Dying
Ethical Perspectives on DyingEthical Perspectives on Dying
Ethical Perspectives on Dyingmeducationdotnet
 

Similar a 59058785 case-study (20)

Medical Ethics In Prisoners Of War
Medical Ethics In Prisoners Of WarMedical Ethics In Prisoners Of War
Medical Ethics In Prisoners Of War
 
Persuasive Essay On Right To Die
Persuasive Essay On Right To DiePersuasive Essay On Right To Die
Persuasive Essay On Right To Die
 
PHI 413V Grand Canyon University Week 4 Personal Experiences Learning.pdf
PHI 413V Grand Canyon University Week 4 Personal Experiences Learning.pdfPHI 413V Grand Canyon University Week 4 Personal Experiences Learning.pdf
PHI 413V Grand Canyon University Week 4 Personal Experiences Learning.pdf
 
The Slippery Slope Of Euthanasia
The Slippery Slope Of EuthanasiaThe Slippery Slope Of Euthanasia
The Slippery Slope Of Euthanasia
 
Ethical Issues Essays
Ethical Issues EssaysEthical Issues Essays
Ethical Issues Essays
 
Ethical And Professional Implications Essay
Ethical And Professional Implications EssayEthical And Professional Implications Essay
Ethical And Professional Implications Essay
 
Carlos Albizu University Week 2 Research Methods in Healthcare Management.docx
Carlos Albizu University Week 2 Research Methods in Healthcare Management.docxCarlos Albizu University Week 2 Research Methods in Healthcare Management.docx
Carlos Albizu University Week 2 Research Methods in Healthcare Management.docx
 
The Mental Capacity Act 2005
The Mental Capacity Act 2005The Mental Capacity Act 2005
The Mental Capacity Act 2005
 
Euthanasia
EuthanasiaEuthanasia
Euthanasia
 
End of life decisions
End of life decisionsEnd of life decisions
End of life decisions
 
Persuasive Essay Euthanasia
Persuasive Essay EuthanasiaPersuasive Essay Euthanasia
Persuasive Essay Euthanasia
 
Personal Experiences Learning Discussion.pdf
Personal Experiences Learning Discussion.pdfPersonal Experiences Learning Discussion.pdf
Personal Experiences Learning Discussion.pdf
 
Essay On Advance Directives
Essay On Advance DirectivesEssay On Advance Directives
Essay On Advance Directives
 
Animal Euthanasia Pros And Cons
Animal Euthanasia Pros And ConsAnimal Euthanasia Pros And Cons
Animal Euthanasia Pros And Cons
 
Bioethics intoduction
Bioethics intoductionBioethics intoduction
Bioethics intoduction
 
For Euthanasia Persuasive Essay
For Euthanasia Persuasive EssayFor Euthanasia Persuasive Essay
For Euthanasia Persuasive Essay
 
Medical Ethics Essay
Medical Ethics EssayMedical Ethics Essay
Medical Ethics Essay
 
CHAPTER18End-of-Life Issues© sfam_photoShutterstockWhen
CHAPTER18End-of-Life Issues© sfam_photoShutterstockWhenCHAPTER18End-of-Life Issues© sfam_photoShutterstockWhen
CHAPTER18End-of-Life Issues© sfam_photoShutterstockWhen
 
Ethical Perspectives on Dying
Ethical Perspectives on DyingEthical Perspectives on Dying
Ethical Perspectives on Dying
 
Personalized Medicine Essay
Personalized Medicine EssayPersonalized Medicine Essay
Personalized Medicine Essay
 

Más de homeworkping3

238304497 case-digest
238304497 case-digest238304497 case-digest
238304497 case-digesthomeworkping3
 
238247664 crim1 cases-2
238247664 crim1 cases-2238247664 crim1 cases-2
238247664 crim1 cases-2homeworkping3
 
238234981 swamping-and-spoonfeeding
238234981 swamping-and-spoonfeeding238234981 swamping-and-spoonfeeding
238234981 swamping-and-spoonfeedinghomeworkping3
 
238218643 jit final-manual-of-power-elx
238218643 jit final-manual-of-power-elx238218643 jit final-manual-of-power-elx
238218643 jit final-manual-of-power-elxhomeworkping3
 
238103493 stat con-cases-set
238103493 stat con-cases-set238103493 stat con-cases-set
238103493 stat con-cases-sethomeworkping3
 
238097308 envi-cases-full
238097308 envi-cases-full238097308 envi-cases-full
238097308 envi-cases-fullhomeworkping3
 
238057020 envi-air-water
238057020 envi-air-water238057020 envi-air-water
238057020 envi-air-waterhomeworkping3
 
238019494 rule-06-kinds-of-pleadings
238019494 rule-06-kinds-of-pleadings238019494 rule-06-kinds-of-pleadings
238019494 rule-06-kinds-of-pleadingshomeworkping3
 
237978847 pipin-study-7
237978847 pipin-study-7237978847 pipin-study-7
237978847 pipin-study-7homeworkping3
 
237962770 arthur-lim-et-case
237962770 arthur-lim-et-case237962770 arthur-lim-et-case
237962770 arthur-lim-et-casehomeworkping3
 
237778794 ethical-issues-case-studies
237778794 ethical-issues-case-studies237778794 ethical-issues-case-studies
237778794 ethical-issues-case-studieshomeworkping3
 
237754196 case-study
237754196 case-study237754196 case-study
237754196 case-studyhomeworkping3
 
237750650 labour-turnover
237750650 labour-turnover237750650 labour-turnover
237750650 labour-turnoverhomeworkping3
 
237712710 case-study
237712710 case-study237712710 case-study
237712710 case-studyhomeworkping3
 
237654933 mathematics-t-form-6
237654933 mathematics-t-form-6237654933 mathematics-t-form-6
237654933 mathematics-t-form-6homeworkping3
 

Más de homeworkping3 (20)

238304497 case-digest
238304497 case-digest238304497 case-digest
238304497 case-digest
 
238247664 crim1 cases-2
238247664 crim1 cases-2238247664 crim1 cases-2
238247664 crim1 cases-2
 
238234981 swamping-and-spoonfeeding
238234981 swamping-and-spoonfeeding238234981 swamping-and-spoonfeeding
238234981 swamping-and-spoonfeeding
 
238218643 jit final-manual-of-power-elx
238218643 jit final-manual-of-power-elx238218643 jit final-manual-of-power-elx
238218643 jit final-manual-of-power-elx
 
238103493 stat con-cases-set
238103493 stat con-cases-set238103493 stat con-cases-set
238103493 stat con-cases-set
 
238097308 envi-cases-full
238097308 envi-cases-full238097308 envi-cases-full
238097308 envi-cases-full
 
238057402 forestry
238057402 forestry238057402 forestry
238057402 forestry
 
238057020 envi-air-water
238057020 envi-air-water238057020 envi-air-water
238057020 envi-air-water
 
238056086 t6-g6
238056086 t6-g6238056086 t6-g6
238056086 t6-g6
 
238019494 rule-06-kinds-of-pleadings
238019494 rule-06-kinds-of-pleadings238019494 rule-06-kinds-of-pleadings
238019494 rule-06-kinds-of-pleadings
 
237978847 pipin-study-7
237978847 pipin-study-7237978847 pipin-study-7
237978847 pipin-study-7
 
237968686 evs-1
237968686 evs-1237968686 evs-1
237968686 evs-1
 
237962770 arthur-lim-et-case
237962770 arthur-lim-et-case237962770 arthur-lim-et-case
237962770 arthur-lim-et-case
 
237922817 city-cell
237922817 city-cell237922817 city-cell
237922817 city-cell
 
237778794 ethical-issues-case-studies
237778794 ethical-issues-case-studies237778794 ethical-issues-case-studies
237778794 ethical-issues-case-studies
 
237768769 case
237768769 case237768769 case
237768769 case
 
237754196 case-study
237754196 case-study237754196 case-study
237754196 case-study
 
237750650 labour-turnover
237750650 labour-turnover237750650 labour-turnover
237750650 labour-turnover
 
237712710 case-study
237712710 case-study237712710 case-study
237712710 case-study
 
237654933 mathematics-t-form-6
237654933 mathematics-t-form-6237654933 mathematics-t-form-6
237654933 mathematics-t-form-6
 

Último

How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17Celine George
 
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...Nguyen Thanh Tu Collection
 
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptxSandy Millin
 
Protein Structure - threading Protein modelling pptx
Protein Structure - threading Protein modelling pptxProtein Structure - threading Protein modelling pptx
Protein Structure - threading Protein modelling pptxvidhisharma994099
 
What is the Future of QuickBooks DeskTop?
What is the Future of QuickBooks DeskTop?What is the Future of QuickBooks DeskTop?
What is the Future of QuickBooks DeskTop?TechSoup
 
Patient Counselling. Definition of patient counseling; steps involved in pati...
Patient Counselling. Definition of patient counseling; steps involved in pati...Patient Counselling. Definition of patient counseling; steps involved in pati...
Patient Counselling. Definition of patient counseling; steps involved in pati...raviapr7
 
Department of Health Compounder Question ‍Solution 2022.pdf
Department of Health Compounder Question ‍Solution 2022.pdfDepartment of Health Compounder Question ‍Solution 2022.pdf
Department of Health Compounder Question ‍Solution 2022.pdfMohonDas
 
Prescribed medication order and communication skills.pptx
Prescribed medication order and communication skills.pptxPrescribed medication order and communication skills.pptx
Prescribed medication order and communication skills.pptxraviapr7
 
AUDIENCE THEORY -- FANDOM -- JENKINS.pptx
AUDIENCE THEORY -- FANDOM -- JENKINS.pptxAUDIENCE THEORY -- FANDOM -- JENKINS.pptx
AUDIENCE THEORY -- FANDOM -- JENKINS.pptxiammrhaywood
 
How to Create a Toggle Button in Odoo 17
How to Create a Toggle Button in Odoo 17How to Create a Toggle Button in Odoo 17
How to Create a Toggle Button in Odoo 17Celine George
 
HED Office Sohayok Exam Question Solution 2023.pdf
HED Office Sohayok Exam Question Solution 2023.pdfHED Office Sohayok Exam Question Solution 2023.pdf
HED Office Sohayok Exam Question Solution 2023.pdfMohonDas
 
10 Topics For MBA Project Report [HR].pdf
10 Topics For MBA Project Report [HR].pdf10 Topics For MBA Project Report [HR].pdf
10 Topics For MBA Project Report [HR].pdfJayanti Pande
 
A gentle introduction to Artificial Intelligence
A gentle introduction to Artificial IntelligenceA gentle introduction to Artificial Intelligence
A gentle introduction to Artificial IntelligenceApostolos Syropoulos
 
ARTICULAR DISC OF TEMPOROMANDIBULAR JOINT
ARTICULAR DISC OF TEMPOROMANDIBULAR JOINTARTICULAR DISC OF TEMPOROMANDIBULAR JOINT
ARTICULAR DISC OF TEMPOROMANDIBULAR JOINTDR. SNEHA NAIR
 
Quality Assurance_GOOD LABORATORY PRACTICE
Quality Assurance_GOOD LABORATORY PRACTICEQuality Assurance_GOOD LABORATORY PRACTICE
Quality Assurance_GOOD LABORATORY PRACTICESayali Powar
 
How to Send Emails From Odoo 17 Using Code
How to Send Emails From Odoo 17 Using CodeHow to Send Emails From Odoo 17 Using Code
How to Send Emails From Odoo 17 Using CodeCeline George
 
Education and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptxEducation and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptxraviapr7
 
SOLIDE WASTE in Cameroon,,,,,,,,,,,,,,,,,,,,,,,,,,,.pptx
SOLIDE WASTE in Cameroon,,,,,,,,,,,,,,,,,,,,,,,,,,,.pptxSOLIDE WASTE in Cameroon,,,,,,,,,,,,,,,,,,,,,,,,,,,.pptx
SOLIDE WASTE in Cameroon,,,,,,,,,,,,,,,,,,,,,,,,,,,.pptxSyedNadeemGillANi
 
KARNAADA.pptx made by - saransh dwivedi ( SD ) - SHALAKYA TANTRA - ENT - 4...
KARNAADA.pptx  made by -  saransh dwivedi ( SD ) -  SHALAKYA TANTRA - ENT - 4...KARNAADA.pptx  made by -  saransh dwivedi ( SD ) -  SHALAKYA TANTRA - ENT - 4...
KARNAADA.pptx made by - saransh dwivedi ( SD ) - SHALAKYA TANTRA - ENT - 4...M56BOOKSTORE PRODUCT/SERVICE
 

Último (20)

How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17
 
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...
CHUYÊN ĐỀ DẠY THÊM TIẾNG ANH LỚP 11 - GLOBAL SUCCESS - NĂM HỌC 2023-2024 - HK...
 
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
 
Protein Structure - threading Protein modelling pptx
Protein Structure - threading Protein modelling pptxProtein Structure - threading Protein modelling pptx
Protein Structure - threading Protein modelling pptx
 
What is the Future of QuickBooks DeskTop?
What is the Future of QuickBooks DeskTop?What is the Future of QuickBooks DeskTop?
What is the Future of QuickBooks DeskTop?
 
Patient Counselling. Definition of patient counseling; steps involved in pati...
Patient Counselling. Definition of patient counseling; steps involved in pati...Patient Counselling. Definition of patient counseling; steps involved in pati...
Patient Counselling. Definition of patient counseling; steps involved in pati...
 
Department of Health Compounder Question ‍Solution 2022.pdf
Department of Health Compounder Question ‍Solution 2022.pdfDepartment of Health Compounder Question ‍Solution 2022.pdf
Department of Health Compounder Question ‍Solution 2022.pdf
 
Prescribed medication order and communication skills.pptx
Prescribed medication order and communication skills.pptxPrescribed medication order and communication skills.pptx
Prescribed medication order and communication skills.pptx
 
AUDIENCE THEORY -- FANDOM -- JENKINS.pptx
AUDIENCE THEORY -- FANDOM -- JENKINS.pptxAUDIENCE THEORY -- FANDOM -- JENKINS.pptx
AUDIENCE THEORY -- FANDOM -- JENKINS.pptx
 
How to Create a Toggle Button in Odoo 17
How to Create a Toggle Button in Odoo 17How to Create a Toggle Button in Odoo 17
How to Create a Toggle Button in Odoo 17
 
HED Office Sohayok Exam Question Solution 2023.pdf
HED Office Sohayok Exam Question Solution 2023.pdfHED Office Sohayok Exam Question Solution 2023.pdf
HED Office Sohayok Exam Question Solution 2023.pdf
 
10 Topics For MBA Project Report [HR].pdf
10 Topics For MBA Project Report [HR].pdf10 Topics For MBA Project Report [HR].pdf
10 Topics For MBA Project Report [HR].pdf
 
March 2024 Directors Meeting, Division of Student Affairs and Academic Support
March 2024 Directors Meeting, Division of Student Affairs and Academic SupportMarch 2024 Directors Meeting, Division of Student Affairs and Academic Support
March 2024 Directors Meeting, Division of Student Affairs and Academic Support
 
A gentle introduction to Artificial Intelligence
A gentle introduction to Artificial IntelligenceA gentle introduction to Artificial Intelligence
A gentle introduction to Artificial Intelligence
 
ARTICULAR DISC OF TEMPOROMANDIBULAR JOINT
ARTICULAR DISC OF TEMPOROMANDIBULAR JOINTARTICULAR DISC OF TEMPOROMANDIBULAR JOINT
ARTICULAR DISC OF TEMPOROMANDIBULAR JOINT
 
Quality Assurance_GOOD LABORATORY PRACTICE
Quality Assurance_GOOD LABORATORY PRACTICEQuality Assurance_GOOD LABORATORY PRACTICE
Quality Assurance_GOOD LABORATORY PRACTICE
 
How to Send Emails From Odoo 17 Using Code
How to Send Emails From Odoo 17 Using CodeHow to Send Emails From Odoo 17 Using Code
How to Send Emails From Odoo 17 Using Code
 
Education and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptxEducation and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptx
 
SOLIDE WASTE in Cameroon,,,,,,,,,,,,,,,,,,,,,,,,,,,.pptx
SOLIDE WASTE in Cameroon,,,,,,,,,,,,,,,,,,,,,,,,,,,.pptxSOLIDE WASTE in Cameroon,,,,,,,,,,,,,,,,,,,,,,,,,,,.pptx
SOLIDE WASTE in Cameroon,,,,,,,,,,,,,,,,,,,,,,,,,,,.pptx
 
KARNAADA.pptx made by - saransh dwivedi ( SD ) - SHALAKYA TANTRA - ENT - 4...
KARNAADA.pptx  made by -  saransh dwivedi ( SD ) -  SHALAKYA TANTRA - ENT - 4...KARNAADA.pptx  made by -  saransh dwivedi ( SD ) -  SHALAKYA TANTRA - ENT - 4...
KARNAADA.pptx made by - saransh dwivedi ( SD ) - SHALAKYA TANTRA - ENT - 4...
 

59058785 case-study

  • 1. Case study: an ethical dilemma involving a dying patient by Alsacia L. Pacsi Abstract Nursing often deals with ethical dilemmas in the clinical arena. A case study demonstrates an ethical dilemma faced by healthcare providers who care for and treat Jehovah's Witnesses who are placed in a critical situation due to medical life-threatening situations. A 20-year-old, pregnant, Black Hispanic female presented to the Emergency Department (ED) in critical condition following a single-vehicle car accident. She exhibited signs and symptoms of internal bleeding and was advised to have a blood transfusion and emergency surgery in an attempt to save her and the fetus. She refused to accept blood or blood products and rejected the surgery as well. Her refusal was based on a fear of blood transfusion due to her belief in Bible scripture. The ethical dilemma presented is whether to respect the patient's autonomy and compromise standards of care or ignore the patient's wishes in an attempt to save her life. This paper presents the clinical case, identifies the ethical dilemma, and discusses virtue ethical theory and principles that apply to this situation. "Juana" (fictitious name) a 20-year-old, Black Hispanic female, 32 weeks pregnant, was brought to the emergency department (ED) in an ambulance by the paramedics. She arrived in the ED immobilized on a flat board with a hard cervical collar in place. Juana was the driver of a sedan involved in a single-vehicle collision. She stated she was driving at approximately 60 miles per hour on the highway and suddenly lost control of the vehicle and crashed into a light pole. She also stated her head hit the windshield and shattered the glass. She denied loss of consciousness. Upon her arrival in the ED, Juana was alert and oriented to person, place, and time and had a Glasgow Coma Scale of 15/15. Her initial complaints were lightheadedness, weakness, left shoulder pain, and severe abdominal cramping that started immediately following the car accident. She had a past medical history of sickle cell disease and no previous pregnancies. Her lungs were clear bilaterally. Juana's heart rate was 90 beats per minute (bpm), her respiratory rate was 28, and her initial blood pressure (BP) was 130/80, and fetal pulse rate was 90. Once the cervical spine films were taken and the flat board was removed, her BP reflected orthostatic changes of 100/60 and pulse of 120 bpm. Diagnosis and interventions Juana was placed on a 100% nonrebreather mask. Peripheral intravenous lines were started bilaterally to replace fluid loss that was indicated by the change in vital signs. It was suspected that she was bleeding internally into her thoracic or abdominal cavity. Blood specimens were drawn and sent to the laboratory. A hemoglobin of 6 g/dl and hematocrit of 21% indicated internal bleeding. Ultrasound showed blood in the amniotic cavity and Doppler confirmed a fetal heart rate of 90 bpm indicating fetal distress. The patient was informed by the medical team of the critical nature of her condition. The plan of care for her was an immediate blood transfusion and an emergency cesarean section. Matters became complicated when Juana informed the medical team that she was a Jehovah's Witness and refused the proposed plan of care. The physician then recommended the use of alternative blood products. Juana insisted that this was also against her religion and she refused the alternative treatments being offered. The medical team advised her that Jehovah's Witnesses could choose certain blood byproducts, such as albumin, cryoprecipitate, and globulin (Watchtower Bible and Tract Society, 2004).
  • 2. According to Juana and her husband, both believed that if she accepted the blood transfusion or blood products she would no longer be a Jehovah's Witness and would be condemned to hell. The husband then presented the physician with Juana's blood card, created by the Watchtower Bible and Tract Society, the governing organization of Jehovah's Witnesses. The card stated her advance directives, including the prohibition of blood and blood products. The beliefs of Jehovah's Witnesses stem from their interpretation of passages from the old testament of the Bible, which they believe is the inspired word of God (Watchtower, 2004). For example, according to the New World Translation of the Bible, blood symbolizes the life of the person or animal (Gen.9.36). Revelations (1.5) states, "The only appropriate use of blood is the sacrificial blood of Jesus." Another passage that Jehovah's Witnesses emphasize declares, "And whatsoever man there is among you, that eateth any manner of blood, I will even set my face against that soul that eats blood, and will cut him off from among his people" (Lev.7.10-14). Juana's condition worsened within 2 hours of admission to the ED. She went into labor and delivered a stillborn baby boy. She was immediately transferred to the intensive care unit where, despite continued aggressive attempts to stabilize her, she went into cardiac arrest and died. The ethical dilemma This case presents an ethical dilemma, a situation which arises when one must choose between mutually exclusive alternatives (Beauchamp & Walters, 2003). Decisions may have results that are desirable in some respects and undesirable in others. In Juana's case, her decision to refuse the blood transfusion had the desired outcome of allowing her to remain true to her religious beliefs. However, her choice also resulted in her death. If she had followed the recommendation of the physicians and the team, the desirable outcome would have been possible survival but would have had the undesired effect of violating her religious principles. The major ethical dilemma was that by honoring the patient's autonomy and religious beliefs, the physicians and interdisciplinary team were faced with compromising their moral duty to administer professional care in accordance with established standards (Chua & Tham, 2006). A brief review of the literature of Nursing Collection II: Lippincott Nursing Journals (from Ovid) and CINAHL databases for the past 5 years found no evidence to support best practice for a Jehovah's Witness who is pregnant and has experienced blunt trauma. Healthcare providers faced with this situation have sometimes attempted to obtain court orders that would overrule the patient's decision and result in her submitting to recommended medical treatment. For example, the Illinois Supreme Court (Illinois v. Brown, 1996) upheld a mother's decision to refuse blood transfusions even though they were vital for both the mother's and fetus' survival. The Patient's Bill of Rights states that the healthcare providers' responsibility is to give patients accurate information and that patients must consent to treatment (New York State Department of Health, 2008). This is consistent with the Federal government's recommendations to create guidelines that assure healthcare quality and to reaffirm the critical role consumers play in safeguarding their own health, (United States Department of Health and Human Services, 1999). Nursing practice is governed by the patient's right to autonomy rather than her religious beliefs (Levy, 1999). The first item in the American Nurses Association (ANA) Code for Nurses with Interpretative Statements (2001) addresses respect for human dignity: "Truth telling and the process of reaching informed choice underlie the exercise of self-determination, which is basic to respect for person ... Clients have the moral right to determine what will be done with their own person; to be given accurate information, and all the information necessary for making informed judgments; to be assisted with
  • 3. weighing the benefits and burdens of options in their treatment; to accept, refuse, or terminate treatment without coercion; and to be given necessary emotional support" (p. 1). However, it is difficult to witness death based on a person's decision to forgo care when medical options to sustain life are available. Treating this type of patient becomes particularly challenging when it involves two lives. Virtue ethics To analyze this ethical dilemma, the principles of Western medicine and the religious beliefs of Jehovah's Witnesses were examined. The questions that surfaced were (a) how would the application of virtue ethics provide insight into Juana's situation, (b) what were the ethical principles in conflict, and (c) why was it an issue to administer a blood transfusion to Juana in an emergency situation. Volbrecht's framework for ethical analysis was utilized to address the clinical dilemma and the questions listed above. Virtue ethics was the primary theory employed prior to the 17th century. This theory centers on shared familial and cultural histories and religious traditions and acknowledges the community's ability to identify, interpret, prioritize, and adjust to moral considerations within a particular context (Volbrecht, 2002). The following is an exposition of this case according to virtue ethics. MoreArticles of Interest • Case Studies in Nursing Ethics • An ethical dilemma involving a shy-drager patient: a case study • Dealing with ethical dilemmas: nurses regularly face ethical challenges in... • Is it an ethical dilemma for sure? - Speaking of Ethics - case study of... • An ethical dilemma: who should know and who should tell Virtue ethics focuses on what is morally correct from the patient's viewpoint and centers on the patient's autonomy. Actions and character are intertwined, and the ability to act morally is contingent on one's moral character and integrity. Virtue ethics focuses on the context of the situation (Volbrecht, 2002). Ethical analysis of virtue ethics entails (a) identifying the problem, (b) analyzing context, (c) exploring options, (d) applying the decision process, and (e) implementing the plan and evaluating results (Volbrecht, 2002). Identifying the problem Juana, a 20-year-old Hispanic woman, 32 weeks pregnant, was involved in a car accident. Internal bleeding to the thoracic or abdominal cavity was suspected. The stakeholders were the woman, her husband, the fetus, and the interdisciplinary healthcare team. The team thought the best method of treatment for this patient was to administer a blood transfusion and perform an emergency cesarean section. Both the patient and her husband refused this option because of their religious beliefs and provided written documentation indicating that the patient would not accept blood or blood products. The value issues were the physical survival of the woman and her fetus versus the woman's religious integrity. Analyzing context To understand the decision-making process in this case, one must consider the ethical principles of autonomy, beneficence, nonmaleficence, justice, compassion, and respect. The patient's religious beliefs and how they
  • 4. influenced her decision must also be taken into consideration. Gardiner (2003) confirms that the ethical principles mentioned above influence one's choices. In Juana's case, the healthcare team suspected she was experiencing internal bleeding and that she and the fetus were in physiological distress. Juana's decision to reject the proposed treatment was based on her stated religious beliefs. The contextual factors of this case centered on the patient's religious beliefs. The patient stated she would "rather be embraced in the hollow bosom of Jehovah than to be condemned for all eternity," if she should receive a blood transfusion. Nurses draw from the code of ethics to reflect upon and understand the person's perspective, and to honor her wishes. "The nurse provides services with respect for human dignity and the uniqueness of the client, unrestricted by considerations of social or economic status, personal attributes or the nature of the health problem" (ANA, 2001, p.1). To respect the patient's decision and honor her dignity, supportive care was provided to the patient in an effort to save her life, while at the same time respecting her wishes. The ANA Code of Ethics supports the point of view that healthcare providers should respect patients' wishes and decisions despite their own personal beliefs (ANA, 2001). Applying an ethical decision process Looking through the lens of virtue ethics, the caregivers focused on Juana's autonomy and her right to choose what she perceived best in spite of the possible outcomes. Juana was a competent, pregnant woman who made informed decisions not to receive blood transfusions or a caesarean section. Based on virtue ethics, the healthcare providers respected the patient's autonomy by reflecting on and honoring the decision of the patient and her husband based on her religious values and beliefs. The healthcare providers also drew on the principle of beneficence, which centers on promoting the well-being of others. In this case, the well-being was not physiological but spiritually oriented. The principle of nonmaleficence was also employed by not intentionally inflicting harm on the patient and honoring her wishes. Violation of a client's deeply held beliefs is a form of doing harm. (Leonard & Plotnikoff, 2000). They also drew from the principles of veracity and respect, which entail being truthful to the patient and allowing her to make an informed decision (Volbrecht, 2002). The nursing virtues of compassion, moral courage, and self-reliance also contribute to an understanding of this situation. Evaluating results At the time this clinical situation presented itself there were no specific guidelines in the institution for dealing with the dilemma presented by this case. However, there are guidelines for Jehovah's Witnesses specifically geared to early identification and management of gynecological patients. For example, in Australasia, there are specific guidelines for treating pregnant women that focus on stabilizing the patient by using traditional and new treatment modalities to meet patient needs, particularly for Jehovah's Witnesses or other patients who decline blood transfusions (Women's Hospitals Australasia, 2005). For antepartum patients, the guidelines focus on early identification of Jehovah's Witnesses during prenatal visits, as well as placing these patients on a high risk protocol, including maintenance of high hemoglobin and hematocrit levels, having advance directives completed, and establishing affiliations with other hospitals that are well-equipped and staffed to meet these patients' needs (Women's Hospitals Australasia, 2005). The Hartford Hospital in Connecticut has a similar program and also performs bloodless procedures on patients who are Jehovah's Witnesses (Miller, 1996). MoreArticles of Interest • Case Studies in Nursing Ethics
  • 5. • An ethical dilemma involving a shy-drager patient: a case study • Dealing with ethical dilemmas: nurses regularly face ethical challenges in... • Is it an ethical dilemma for sure? - Speaking of Ethics - case study of... • An ethical dilemma: who should know and who should tell As a result of Juana's case being reviewed by the ethics committee post-mortem, a risk-management protocol was developed requiring patients who refuse blood transfusions to sign a waiver that removes the legal responsibility for the decision from the hospital and caregivers. To support this type of protocol, the Society for the Advancement of Blood Management maintains a database of hospitals that provide blood-conserving services in the United States as well as in Canada, Chile, Korea, and South Africa (Society for the Advancement of Blood Management, 2008). The problem, however, in an emergency situation is that it may not be possible to get the patient to a participating hospital. The Watchtower Bible and Tract Society (2004) recommends that advance directives and other legal papers be in place should an emergency arise. These documents should be easily accessible so that healthcare providers can honor the patient's directives. In so doing, they will be applying the theory of virtue ethics and, therefore, respect the patient's wishes (Macklin, 2003). Healthcare providers should practice beneficence and non- maleficence without imposing their beliefs as to the right thing to do. More explicit and universal guidelines would benefit both patients and providers when faced with similar ethical dilemmas.
  • 6. Ethical dilemma and resolution: a case scenario Joseph K Wells1 Abstract This article illustrates an ethical dilemma that I faced while treating an 86-year-old woman at her home. The ethical dilemma was caused due to several factors such as the expectations of the client (client/ consumer rights), organisational expectations (employer, governmental and payer-source regulations) and my own personal values (one's moral philosophies, perceived social responsibilities, sense of professional duty) and how they all interact with each other. The case is a classic example of a seemingly simple yet frequent dilemma encountered by occupational and physical therapists in the United States serving clients who are covered by Medicare (the government's health insurance) for home health. The article is aimed at highlighting the various ethical principles involved in clinical decision-making, and it suggests methods for resolution of ethical dilemmas. Although the article is based against the backdrop of the US health care system, students and health care practitioners globally can relate to it. The ethical dilemma in the case discussed below involved whether or not to continue treating a client who clearly needed occupational therapy services based on medical necessity, yet the payer-source (Medicare) coverage criteria for services to be delivered at home was questionable. That is, should one continue to treat the client and uphold the principle of beneficence yet run afoul of the law, or should one discontinue treating the client to uphold the law but possibly cause harm to the client? The case scenario Three years ago, Ms EH, an 86-year-old woman, was referred to me after a debilitating stroke affected her right side (pre-morbidly her dominant side). Ms EH was admitted under home health after running out of Medicare allowable days at a skilled nursing facility (SNF). Ms EH needed considerable assistance with all activities of daily living (ADL) and was primarily wheelchair-bound due to her inability to walk independently. She lived with her 88-year-old husband Mr. RH, who was also not in the best of health. Due to financial constraints the couple opted against long-term or assisted living placement in favour of their trailer home. Ms EH demonstrated good rehabilitation potential and progress with all her home health services. One night, approximately three weeks after her return home from the SNF, Mr. RH suffered a massive myocardial infarction. He was hospitalised and underwent cardiac catheterisation. It indicated diffuse blockage of multiple vessels and he was deemed a poor candidate for surgery. Subsequent medical interventions were primarily conservative with a poor prognosis. He was later transferred to a nursing home. Ms EH obviously was very concerned and depressed about the situation. She was devoted and would visit Mr. RH for four to six hours everyday at the nursing home after being driven there by her friends and family. No one could persuade Ms EH to avoid the exertion. She would simply state, " He has always been there for me. Shouldn't I?" Soon after her husband's admission to the nursing home, Ms EH began to have difficulty keeping up with her appointments with me and the other home health providers. Medicare's guidelines for clients to receive home health under Part-A Insurance Plan require them to meet certain "homebound" criteria. The Center for Medicare and Medicaid Services (CMS), formerly called the Health Care Financing Agency (HCFA), describing homebound status states that, "there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort. If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment..." (1). Ethical principles at risk As per organisational requirements (Medicare's as the regulatory and the home health agency's as the regulated body), Ms EH was clearly homebound based upon her physical limitations; however, her daily absences did not exactly fit the "infrequent" or "short-duration" requirements for Medicare coverage. Much
  • 7. of the ethical confusion was also caused due to the inability of the coverage guideline to exactly quantify the terms "infrequent" and "short duration" and leaving it for further interpretations. The client's expectation and what could be perceived as her right to receive health care at her home based upon her medical necessity (client/consumer rights), and my moral duty to provide treatments and my obligation toward her well-being (my personal beliefs) were thus in conflict with the organisational interpretation/ procedures based on regulations that set criteria for services (rules of practice, possible legal issues involved). The various ethical principles at risk were as follows: Autonomy: The client's right based upon her self-determination to receive occupational therapy services at home, and my own professional autonomy to decide where the client should receive the services were under question. As stated by Shanawani and Lowe, our professional schooling prepares us with, "guidelines, rules and regulations, and legal judgments relevant to our decisions about where to treat patients...(based on) medical variables of the patient's health... and the anticipated care needs of the patient. Nowhere do non-medical [italics added] variables of patient financial resources, insurance reimbursement, and patient and family preference play an explicit role in those decisions" (2). Veracity: My professional obligation to speak and act truthfully regarding the client's inability to follow the homebound criteria to continue receiving services at home interfered with my respect for the client's autonomy. Justice: While I felt a strong sense of duty to care for my client, I realised that the client did not clearly satisfy all Medicare coverage criteria (3). Fidelity: I viewed this principle as my ability to uphold my commitments to all parties involved, such as the client, my organisation, and the government (via Medicare regulations) and my self as a moral agent. Beneficence: The client strongly believed that she needed home occupational therapy services and that she was truly benefiting from these. In my professional judgement, too, the client certainly could benefit with continued services. However, this beneficence seemed to conflict with the legal and ethical aspects of delivering services. Other ethical principles caused me to introspect on what kinds of consequences were good or valuable. I hoped that I was able to be truthful, moral and of benefit to my client through my actions. I also contemplated on what would be a virtuous route to meet the care needs of my client, act in her best interests and cause her maximum gains. My dilemma forced me to explore the meta-ethical bases of these principles, since several principles were at risk or were conflicting. Do I resolve my ethics based on reason as taught by Immanuel Kant or do I base it on sympathy as proposed by Hume? Do my professional duties conflict with my personal religious beliefs to do good unto others? Will my social contract as a therapist be broken if I discharged my client from my care since she did not meet the Medicare (legal) requirements (4)? The theories of ethics applicable to my dilemma My dilemma involved various ethical principles that are based upon different ethical theories. My case, as with most occurrences in health care, had elements of all major ethical theories. The theories influencing my decision process were: (a) Teleology, in my pursuit to benefit my client (consequentialism); (b) Virtue-based ethics to strive for my client to receive the care and goodness that I or any human may hope for; (c) Value-based ethics to be truthful and good as a person and professional and cause happiness for my client, and (d) Ethics of care due to the therapist-client relationship I had developed and my concern for my client's care. However, I believe that my dilemma and its resolution were derived from and best explained by the theory of deontology.
  • 8. Deontologism focuses on the very action and its process, and the moral rules and principles involved with the act versus the consequences of the action itself. It emphasises that one must act in accordance with rules and principles of ethics such as respect for autonomy, non-malfeasance, beneficence, justice, fidelity, veracity and avoidance of killing (5). That is, it focuses on acting morally based on one's duty versus basing one's action on the results that it causes. The resolution and the methods used After detailed discussions with the client and her family, I discontinued home-based occupational therapy services and referred the client for outpatient rehabilitation. Jonsen, Seigler, and Winslade (1998), Purtillo (1993) and, Trompetter, Hansen, and Kyler-Hutchinson (1998) have all proposed several methods or processing tools to analyse ethical dilemmas (6,7,8). Kornblau and Starling (1999) also proposed a framework for ethical decision-making. It was called the CELIBATE method (an acronym for 'Clinical Ethics and Legal Issues Bait All Therapists Equally'). The acronym acts as a cue for the user of the framework with each letter representing an aspect for analysis (for example: C for clinical situation, E for ethical issues, L for legal issues, I for information, B for brainstorming action steps, A for analysing action steps, T for taking the action and E for evaluating the results) (5). In the course of analysing and applying a methodology to resolve my ethical dilemma, I charted my ethical course via a framework. Based on this model, we can divide the entire ethical process when faced by a dilemma into three phases, namely the ethical encounter, the ethical loading and ethical unloading. The ethical encounter: This phase as applied to my case has been discussed under the section titled 'The case scenario'. The parties involved are the client, my self, the home health agency that employs my services, the CMS, the State Occupational Therapy Board due to its judiciary powers over the practice of occupational therapy, the American Occupational Therapy Association (AOTA) as it regulates the profession and sets codes of ethics (9), the scope (10) and standards of practice (11); the client's family, and the community as a whole based upon the potential impact of my services (or the lack of services) on my client's health and well-being. In the encounter phase, we face all the interacting human and/or organisational components of the ethical issue. The ethical loading: In this phase we analyse the various issues facing us. Whether the law has been violated, or is at risk, or was there just an ethical problem with no legal implications? My dilemma involves whether or not to continue services although there is a medical necessity, but the client may not necessarily meet the coverage criteria for payment. In this case, one may clearly recognise both ethical and legal issues. Legal issues are based upon Medicare and state practice acts governing the profession as well as the AOTA code of ethics (9) and standards of practice (11). This phase bears the load to introspect and discover legal and ethical violations or risks and analyse methods and the future course of action. We have discussed the ethical issues pertaining to my client in the section titled 'Ethical principles at risk'. In this case, we determined that the theory of deontology best guided our course of resolution. The ethical unloading: Based upon my realisation and analysis of the ethical-legal aspects involved, I mainly geared my actions toward ethical resolution since there were no legal violations as yet and no separate legal actions were warranted other than those implied by ethical actions. My ethical actions were aimed at mainly upholding deontological principles by following my professional duty as perceived under Medicare and state practice acts, and by not interfering with the regulation with my own interpretation and attempt to liberalise it. I chose to rather use the regulation in its most restrictive form in order to ensure that no confusing elements could cause further dilemmas. This upheld the cause of justice, veracity, and my fidelity toward the law that governs my professional practice. With the ability to visit her husband at the nursing home at will, the client's autonomy was upheld as well. Ms EH was also counselled on her options to receive services under Medicare Part-B plan at an outpatient rehabilitation clinic or other qualifying health care facilities. Fortunately, the facility where her
  • 9. spouse was admitted agreed to also treat her as an outpatient. The client found this acceptable and feasible as well. My course of action also ensured non- malfeasance and beneficence by ensuring continuity of services desired and needed by the client in an environment that was acceptable to her. It is in this phase where I "unloaded" my ethical burden through actions that I chose based upon my prior experience, training and/or conscience. As with any clinical case, we may view the "ethical encounter" as a phase where we focus on the demographics and situation at hand. The "ethical loading" phase mainly deals with recognising the ethical and legal issues involved (like the diagnostic process), and investigating and selecting the best course of action (formulating a plan for intervention). Finally, the "ethical unloading" phase involves the application of actions/ interventions with the aim of resolving an issue (outcome). Therefore, this phase must also reflect on the effectiveness of the actions/ interventions in meeting the interests of all parties in the situation. Commentary In my opinion, this case presents an ethical conflict frequently faced by home health care providers, where they strive to best serve their clients' needs while navigating through complex financial coverage issues. Emanuel, a physician-philosopher, and Fuchs, an economist, propose the coupling of much- valued freedom of choice with universal health coverage for Americans (12). The scope of this article was not to address the efficacy of the American health policy but to recognise an everyday dilemma faced in the health care arena. Through experience and common knowledge, we know that health care professionals face similar ethical issues globally. Advances in client education and awareness have led to increased sensitivity and applicability of client rights and autonomy. This has also led to several legal developments and awareness of biomedical-ethics internationally. A clinician, more than ever before, must be prepared to not only address the clinical needs of his/ her clients but also base this on socio-cultural and ethical constructs. A sound knowledge of ethical theories and principles helps to guide a clinician's actions. As Abraham Lincoln once stated, "Let us have faith that right makes might, and in that faith, let us, to the end, dare to do our duty as we understand it (13)." References 1. Center for Medicare and Medicaid Services [web page on the Internet]. Home health manual (Rev. 302): Chapter II-Coverage of services. Baltimore (MD): Center for Medicare and Medicaid Services; c2003- [cited 2005 July 24]. Available from: http://www.cMshhs.gov/manuals/11_hha/hh200.asp 2. Shanawani H, Lowe KN. Is Greenacres (SNF) the place to be? Virtual Mentor [serial on the Internet]. 2005 [cited 2005 July 24]; 7 (7). Available from: http://www.ama- assn.org/ama/pub/category/3040.html 3. Prosser WL. Law of torts. St Paul (MN): West Publishing Co; 1971. 4. Veatch RM. The basics of bioethics. 2nd ed. Upper Saddle River (NJ): Prentice Hall; 2000. 5. Kornblau BL, Starling SP. Ethics in rehabilitation: aclinical perspective. Thorafare (NJ): Slack Inc; 1999. p 53-4. 6. Jonsen AR, Seigler M, Winslade WJ. Clinical ethics. New York: McGraw Hill; 1998. 7. Purtillo R. Ethical dimensions in the health professions. Philadelphia, PA: WB Saunders; 1993.
  • 10. 8. Trompetter L, Hansen R, Kyler- Hutchison P. Reference guide to the occupational therapy code of ethics. Bethesda (MD): American Occupational Therapy Association; 1998. 9. American Occupational Therapy Association [web page on Internet]. Occupational therapy codes of ethics. Bethesda (MD): The Association; c2005- [cited 2005 July 25]. Available from:http://www.aota.org/general/docs/ethicscode05.pdf 10. American Occupational Therapy Association [web page on Internet]. Scope of practice. Bethesda (MD): The Association; c2004- [cited 2005 July 25]. Available from:http://www.aota.org/members/area2/docs/scope.pdf 11. American Occupational Therapy Association [web page on the Internet]. Standards of practice for occupational therapy. Bethesda (MD): The Association; c2005- [cited 2005 July 25]. Available from:http://www.aota.org/members/area2/docs/otsp05.pdf 12. Emanuel EJ, Fuchs VR. Health care vouchers�"a proposal for universal change. N Engl J Med. 2005; 352: 1255-1260. 13. Quotable Online [web page on the Internet]. Quotes by subject: Duty quotes. Web Publishing Group, LLC; c2004-[ cited 2005, July 25]. Available from: http://www.quotableonline.com/quotesubjectss.php?subject=Duty&page=2
  • 11. Ethical Dilemma in Today's Business Global interdependence is a compelling dimension of the global business environment, creating demands on international managers to take a positive stance on issues of ethical behavior, social responsibility, economic development in host countries, and environmental protection around the world. However, there were still several large multinational companies indulging in ethically questionable practices. If MNCs behave unethically, it soon comes to the notice of the public and the company’s image is tainted. Multinationals are often worse off for having behaved unethically in the interest of short term gains, as the bad publicity generated by unethical practices leads to far greater losses in the long run. In the challenge of modern society, manager or worker often encounters a situation than challenges one’s ethical beliefs and standards. Managing across border increasingly includes difficult ethical dilemmas. It is less clear where to draw the line between ethical behavior and the corporation’s other concerns, or between the conflicting expectations of ethical behavior among different countries. The paper aims to (1) discuss current ethical dilemmas in global environmental ethics, (2) examine how multinational would address conflicting norms and expectations by illustrating one case study of ethical dilemma and its resolution. Nestlé’s Corporate Crimes 1.0 Nestlé’s ethical dilemmas 1.1. Unethical marketing practices Infant formula In 1977, Nestle got embroiled in a controversy, when it was criticized for using unethical marketing practices endangering consumer health to promote its infant formula in developing nation. A number of aid agencies called for the boycott of Nestle products and this protest continued right into the 1980s, when Nestle agreed to adopt the infant formula marketing code
  • 12. laid down by the World Health Organization and UNICEF. Although Nestle had a charter on infant formula, the company is usually violated the principles laid down in it (Refer to reference3). Genetically Modified Foods Nestle was criticized for using genetically modified (GM)[1] ingredients in its food products, and was accused of dumping products rejected in Europe in developing Asian countries where the laws on GM products were either absent or less stringent. For Kant, the company’s decision makers would have to be willing to advocate marketing the product even if they were themselves in the position of uniformed consumers. Therefore, providing unsafe products standard and ill-informed consumers by Nestle is absolutely wrong. 1.2. Overcharged prices Nestle launched bottled water, called “Pure Life” in some Asian countries like Pakistan andIndia (in 1998 and 2001 respectively). Nestle introduced bottled water, which provided safe clean water but priced it so high that it was unaffordable for the lower income groups. It turned water into a luxury by pricing it around $ 0.4 (in Pakistan) for a one liter bottle. According to utilitarianism, ethical action is evaluated by looking at its consequences, weighing the good effects against the bad effects on all the people affect by it (Shaw & Barry, 2004). Most developing countries laced basic drinking water facilities. A very high water price was charged by Nestle limiting a number of people to buy it. Nestlé’s action produces the worse for the greatest number of South Asian because people could not afford for water which is basic human needs and is sporadic and contaminated in south Asiacountries. 1.3. Unfair labor practices Nestle was one of the biggest purchasers of cocoa from Ivory Coast, a country in West Africa. UNICEF studies and International Labor Organization (2002) revealed that the workers on these plantation lived and worked in poor conditions. They were paid minimal wages and exploited by the land-owners. Most of the workers had been trafficked by bought and sold, making them
  • 13. practically slave labor. Nestle purchased cocoa from these farms despite its awareness of the conditions of the laborers, thus making it a party to their exploitation. Child labor was also employed on the plantation. UNICEF and The International Institute of Tropical Agriculture (IITA) studies (2002) revealed that over 200,000 children were shipped to Ivory Coast and other cocoa producing countries in Western Africa from neighboring countries like Mali and Burkina Faso, to work on the plantations, especially during the harvesting of cocoa or coffee beans. Another unfair labor practice was occurred in Thailand. When a group of 13 workers, wording in a sub-contracting facility of Nestle in Thailand, organized themselves to form a union, Nestle immediately cut the number of orders to that company and asked the company to put the unionized workers on indefinite leave with half pay. The workers were force to quit because of their lowered pay (Manager 2001). In doing so, Nestle had clearly denied these workers their right to organize themselves to better their interests. 1.2. Applying De George’s principles International business ethics refers to the conduct of MNCs in their relationships to all individuals and entities with whom they come into contact (Daft, 2002). Ethical behavior is judged and based largely on the cultural value system and the generally accepted ways of doing business in each country or society. MNC Manager must decide whether to base their ethical standards on those of the host country or those of the home country and whether these different standards can be reconciled (Donalson, 1996). 1.2.1. Do no harm Thompson & Stickerland, (2003, p. 65) asserts that “a company has ethical duties to owners, employees, customers, suppliers, the communities where it operates, and the public at
  • 14. large.” The norm of doing no harm requires Nestlé’s management to look beyond its own interests (i.e., cheap cocoa, and high market-share). Unethical marketing of infant formula and GM foods in developing countries are example of doing harm knowingly and willingly and of benefiting from the lack of legal restraints to the detriment of the eventual consumers. If business follow Kant’s rule, it will provide a quality and safe product to its entire market. Nestle decide to sell unsafe (GM) foods even it knows that the product is unsafe. In addition, Nestlé’s marketing strategy in developing countries was to distribute free samples to nursing mothers, thus getting the baby used to the formula very early in order to get a hold on its captive market. Unethically, Nestlé promoted the use of infant milk formula as a substitute for mother’s milk. This unethical manner causes widespread infant malnutrition and susceptibility to infection, which could even lead to infant death. Following this norm, Nestle should preserve the safety and health of consumers by disclosure of appropriate information, proper labeling and accurate advertising. Workers on cocoa production from Ivory cost were paid below minimal wages and were practiced as slave labor. Despite its awareness of the conditions of the labors, Nestle continued purchased of cocoa from these suppliers. The company must pressurize its suppliers to change because it is in a position of major buyer. Regarding to Nestlé’s inThailand, the company should respect the right of employees to organize for the purpose of collective bargaining. Nestle had better prohibit retaliation to their employees, though disciplinary action, or an anti-harassment policy. In addition to Anti- harassment, companies need to develop policies and procedures to prevent retaliation against individual who file complaints of harassment or discrimination or who participate in their investigation (Zimmerman, 2002). 1.2.2. Do more good In Ivory Coast, Children worked in hazardous conditions using machetes and spraying pesticides and insecticides without the necessary protective equipments. Such exploitation involves in significant Nestlé’s profit since the labors received only a very small proportion of the price paid for the Nestle product by the final consumer. According to the norm of doing more good than harm to host country, Nestle must stop buying cocoa from South Africa, which is under apartheid and uses child labor in hazardous working condition. For a utilitarian, however, these are considerations that can be balanced against other considerations, such as the benefit to others. On the other side of the balance are factors like corporate reputation (Orts, 1995). These factors can make corporate altruism worthwhile in the long run, even at the short-run expense of the
  • 15. stockholders. Nestle should demonstrate its ethical commitment through philanthropic contribution and use of its expertise and resources on numerous social problem in host countries. Importantly, Nestle should integrate social and ethical issue in strategic process (see figure4). Along with an investment appraisal, such planning should include an environmental impact assessment. According to Whetton & Cameron (2005) leadership is the key success for organizational change as well as the key to aligning organizational systems and follower behaviors around a new organizational vision. Ethical leadership practices are necessary prerequisite for organizational effectiveness (Ausguien, 2001). Therefore, Nestle top management must train to be ethical leadership (see Recommendation action in appendix3). Figure4: Integrating social and ethical issues in the strategic management process Social & Ethical Issues Environmental Analysis Establishing Organizational Direction Strategic Implementation Strategic Formulation Strategic Control Source: Adapted from Thompson & Stickerland (2003, p.7) To upgrade company’s ethics, Nestle must impose codes of conduct that treating other person with respect and should provide leadership’s ethical training as leaderships are key person to make a strategic-decision. Examples of codes of conduct include do not use child or forced labor, provide a safe working environment, and respect worker rights to unionize (Refer to figure2). Corporate moral excellence can be alternative to develop Nestlé’s ethical culture. For a corporate to be morally excellent, it must develop and act out of a moral corporate culture (Hoffman, 1994). In a situation with intolerance arise, manager should be guided by precise statements that spell out the behavior and operating practices that Nestlé’s demand. Nestle must be careful when placing a foreign manager in a country whose values are incongruent with his own because this could lead to conflict with local managers, governmental bodies, customers and suppliers. 1.2.3. Respect the human rights of their employees
  • 16. Doing good business and being a good employer is pivotal and important guidelines in doing today’s multinationals. In fact, ethical business must respect for human dignity, and protect the fundamental rights of people. According to Aristotelian, equal should be treated equally and unequal unequally (Hirschman, 2001). This infers that individuals should be treated the same, unless they differ in ways that are relevant to the situation in which they are involved. If labors work the same jobs, they should be paid the same wage. If Nestle pays its labors less than other companies, then Nestle has an injustice in remuneration system. Violating human rights is immoral practices due to Kant’s principle. This indicates that Nestle exploited and treated others as means rather than as ends, as thing rather than as person. Not only does Nestle (exploiter) fail to do its duty to others, but also fails to do this duty to itself; Nestle make itself into an object. 1.2.4. Respect local regulations MNCs are subject to the laws, regulations, and jurisdiction of the countries in which they operate (OECD, 2004). Nestle must not resist against law that protect the country’s workers or consumers, even if such laws make operating in these countries less profitable. It is evidence that Nestle did not respect for domestic rules and regulation. Nestle broke Thai law bys paying workers less than minimum wage and cut them off. For consumer safety, Nestle did not respect the laws and regulations of the countries in which they operate with regard to consumer protection. In China, there is a regulation of GM food, which required that all products which were contained GM ingredients, be labeled explicitly. Despite consist of GM ingredients, Nestle products were not labeled. Indeed, it could not unilaterally continue with its double standard practice and ignore the concerns and demands of the general public in Asia. [1] Genetically modified foods are lab-crated grains, vegetables, fruits and other primary foods. Their use has been somewhat controversial. Some people are concerned about the consequences to their health of the use of these products. European countries require all GM foods to be clearly labeled as such; however, in countries Canada and the US, labeling is optional.
  • 17. Ethical Dilemmas in Business There are many areas where ethical dilemmas arise. Here are five categories of common ethical dilemmas in business: 1. Human resource issues 2. Employee safety issues 3. Conflicts of interest 4. Customer confidence 5. Use of corporate resources We shall discuss ethical dilemmas related to human resource issues here. Human resource issues Human is the most important resource to an organization. Issues associated with human resources occur as a result of employees working together. These issues are by far the largest category of ethical dilemmas in business. The four main types of human resource issues are as follows: • Hiring and Termination Issues Recruitment or hiring process is the first step in selecting human resource into an organization, and will significantly influence the successful performance of the organization. Ethics plays a very important role during the recruitment of new employees. Law and regulations dictate that we have to be ethical in hiring. However, ethical hiring practice goes beyond them as well. It has been widely reported by many researchers that ethical hiring practices actually result in better employees being recruited. It is therefore important that sound ethical rules are followed when hiring a new employee.
  • 18. It is of vital importance that candidates are to be selected based on merits. Applicants are to be hired based purely on merits such as knowledge, skills, and ability in accordance to the needs of the organization. If a company provides any special considerations, for example affirmative action, where certain groups are given special considerations, these considerations should be well stated in the company's policy statement. In any case, any preferential treatment should be one that is legally allowed. While preferential treatments to certain specific group may be allowed, there should be no discrimination to people from any other group due to race, religion, gender, marital or even pregnancy status. Consistency and objectivity during the recruitment process are very important. Criteria, including any changes in the criteria, used for evaluating candidates should be stated and explained to order to avoid unnecessary claim of biasness in the recruitment process. Objective evaluation results in the best employees being recruited while consistency ensures high morale among employees. When we recruit new employees, we should tell the applicants about the true state of the organization. We should not mislead the applicants. In particular, the applicants should be told all pertinent information, including those information that are not publicly known but that will materially affect the new employee's future employment prospect with the organization. We can learn from the case involving Phil McConkey. Phil McConkey was recruited but he was not aware that the company was in the process of being taken over by another entity. One year after joining the company he lost his job with he new company. He sued the company for with-holding important information from me during the recruitment process. He won the case and was awarded $10 million. We should never place misleading job advertisement in order to get applications if we are offering a job contract different from what we advertised for. For instance, if we want to engage independent contractors instead of normal salaried employment. The reason why we choose to engage independent contractors is that we do not have to be burdened with high salary cost for employees that are not competent, but we are willing to compensate employees according to performance. We should always state clearly our terms of employment. In any case, we do not want to be accused of any job scam. We have to be extra careful when we are recruiting employees from organizations that have material dealing with us include our suppliers, customers and competitors. If we are not careful ethical issues very damaging to us can arise. When we employ somebody from our suppliers, the suppliers may feel that we have unethically poached their good employee. After all, it is through the working relationship we have with the suppliers that we can to know the quality of this employee. When we employ somebody from our customers we can be accused of returning favor to that person. This rule applies especially when employing a former senior government employee that has an influence on the awards of contracts to an organization like yours. The case of Ms. Darleen Druyun at the Department of Defense and Mr. Michael Sears at Boeing is a good illustration of the importance of such a rule. In this case, employment favor was apparently granted by Boeing in exchange for favorable consideration for the awards of contracts by
  • 19. Department of Defense. Also, be careful not to employ former government employees for the purpose of lobbying for contracts from their previous government departments. At least, do not do so within the first two years of the employee leaving the government service. It is also not very wise to employ somebody from our competitors because we can be accused of stealing trade secrets from our competitors. If that employee can pass on his previous employer's secrets unethically, what is there to sop him from passing your trade secrets to others? Even though it may not be considered as unethical by some employers, as a matter of courtesy and good public relationship to inform an unsuccessful applicant. When an employee is asked to leave, it is also of vital importance that it is handled with fairness and care. If it is a case of poor performance or disciplines, the employee has to be given prior warning (unless it is violation of a well stated policy or is of a very serious nature) and fair hearing. In any case, do not hurt the dignity of the employee and offer to provide the necessary assistance where appropriate. Before an employee leave for any reason, provide him/her with an opportunity to provide feedback on the overall state of the organization by conducting exit interviews. • Discrimination is the unfair or preferential treatment of a person on the basis of one or more uncontrollable characteristics, including race, gender, age, color, religion, or national origin, as well as handicapped or pregnancy status. Discrimination against others in the workplace can impair your ability to perform your job according to company expectations. In most countries, there are laws that protect potential and current employees from discrimination based on age, race, color, national origin, religion, and gender, as well as pregnancy or handicapped status. • Performance Appraisals are conducted to evaluate an employee’s performance over a set period of time. When evaluating subordinates, one has to remain consistent and objective. Consistency is even more important when evaluating an existing employee than a prospective employee. Consistency requires that you treat every employee's misbehaviour the same way. For example, it would be wrong to punish one employee's tardiness while leaving another employee's tardiness unchecked. In order to maintain objectivity, the company’s standardized evaluation forms should be used. In this way, uniform criteria can be used for the appraisal of all employees under you. Also, all employees in the company are evaluated based on the same criteria. Constant feedback and communication between you and your subordinates is necessary to facilitate a positive and productive working relationship. Don’t wait until periodic performance evaluations to express your observations and suggestions. In fact, it is unethical to base salary adjustments upon performance problems that have not been brought to the employee’ s attention.
  • 20. For employees being evaluated, honesty and acceptance of responsibility for performance problems are important ethical considerations. • Disciplinary issues Disciplining employees is one of the most difficult parts of a manager’s job. Nevertheless, it is vital to the growth and overall success of the organization. Disciplining employees both ensures productivity and sets standards for the future. Discipline should occur immediately after a problem has occurred. It is imperative that the disciplinary actions remain consistent for all employees. A serious disciplinary issue is sexual harassment where female employees (less so for male employees) are subjected to an unwanted sexual behavior that creates an intimidating or hostile work environment. This includes unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature. This conduct is not only unethical, but illegal as well. Research Paper help https://www.homeworkping.com/