Running head: ETHICS

Ethics Case Study

Mary Ellen Cooper
Old Dominion University

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Ethics Case Study

Facts: Mary OConner is a 72 year old female currently on the inpatient psychiatric unit of a
teaching hospital with a past psychiatric history of depression and past medical history of
hypothyroidism, rheumatoid arthritis, breast cancer, and hypertension. She originally presented
to the ED voluntarily accompanied by her daughter for evaluation of depression and inability to
care for herself. She has subsequently been TDOd (temporary detainment order) and then
committed to the psychiatric unit. She is deemed to lack capacity at this time. Per the daughter,
the patient became more depressed after moving from Harrisonburg to Richmond in February,
becoming increasingly more dependent and refusing to perform IADLs (not eating, not
showering, not taking her medication, etc.). Due to her poor self-care, the patient was moved by
her daughter into an independent living facility two weeks ago, where she became aggressive
with her fellow patients, her daughter, and the facility staff.

The Problem: Due to the nature of her illness, Mrs. O Conner lacks insight into her condition,
and will only sporadically accept her medication after much coaxing by the nurse. Judicial
Authorization was obtained by the treatment team to administer medication over objection, but
Mrs. O Conners medication (Prozac, an antidepressant) does not come in intramuscular (IM)
form, the usual method of administering medication over objection. Some members of the
nursing staff, at the urging of the resident on Mrs. Os team, have been covertly adding the
medicine to the patients food and/or drink. Other members of the nursing staff feel that this is a
bad practice (due to its covert nature) that is outside the bounds of the judicial order, and that it
also has the potential to undermine the therapeutic nurse-patient relationship.

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Ethical Question: What would be the best way to ensure the patients rights and prevent a moral
dilemma for the nurses who object to the practice of covert medication administration?

Ethical Framework: The Moral Method. Developed by Thiroux in 1977 and refined for nursing
practice by Halloran in 1982.
MORAL MODEL FOR ETHICAL DECISION MAKING
M = MASSAGE THE DILEMMA
The issues are the covert administration of medication versus informed consent or medication
over objection (over objection, but the patient is not deceived). Patients who are deemed to
currently lack capacity, but are not psychotic or demented (which there may be some rationale
for), have medications hidden in their food/drink. The current culture on the psychiatric unit
allows each nurse to decide if they are comfortable with the practice of covert medication
administration; therefore, residents will go from nurse to nurse until one agrees. The law in
Virginia does not specifically address covert medication administration. The American Nurses
Association (ANA) code of ethics states: The nurse promotes, advocates for, and strives to
protect the health, safety, and rights of the patient (American Nurses Association, 2015).
The stakeholders here are the patient, her daughter, the doctors, and the nurses. The patient is
sporadically willing to take her medicine, but is adamant at other times that she does not want it.
The patients daughters position so far has been to leave the method of medication
administration up to the staff, but she voices some feelings of moral distress over the idea of
tricking her mother. The doctors, on the other hand, seem to have no such compunction.

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Nursing staff, who allow that the patient may need the medicine, express concern regarding the
method. This issue potentially affects all patients, all doctors, and all nurses.
O= OUTLINE THE OPTIONS
There are at least four possible options for resolving this dilemma: 1.) leave things how they are,
with each individual nurse making his/her own decision regarding whether or not to administer
covert medications; 2.) make it policy that the medications will be administered covertly if there
is a physicians order; 3.) make it policy that no one is allowed to covertly administer
medication; 4.) arrange a hospital ethics committee consult.
There are pros and cons for each of these options. Option number 1 has already proven to be
problematic in that it causes conflict amongst staff, in addition to causing moral distress for those
opposed. One benefit of this option is that no change would be required. Option number 2 could
cause even more moral distress for those opposed, as they would be forced to comply with a
practice they consider ethically suspect. The benefit would be consistency. With option number
3, there is a risk of alienating the medical residents. The benefit would again be consistent
practice. Option number 4 could potentially interfere with the doctor-patient relationship, but
would confer the benefits of giving all stakeholders a voice, provide time for reflection away
from the busy acute clinical setting, and ensure that the unit remains conscious of itself as a
moral community (Gillon, 1997, p. 203).
R= REVIEW CRITERIA AND RESOLVE
After reviewing the issues and options, the option of arranging a hospital ethics consult is chosen
as the best alternative after applying the ethical principles of autonomy, beneficence, veracity,
paternalism, non-maleficence, fidelity, justice, and respect to each option. An ethics consult will

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produce the most good and do the least harm, as well as respect the rights and dignity of all
stakeholders.
A= AFFIRM POSITION AND ACT
The option chosen is affirmed by the American Nurses Association (ANA) Code of Ethics,
Provision 6:
The nurse, through individual and collective effort, establishes, maintains, and improves the
ethical environment of the work setting and conditions of employment that are conducive to safe,
quality health care (American Nurses Association, 2015).
An ethics consult was therefore arranged with all stakeholders included.

L= LOOK BACK
On reflection, this intervention was successful in that it allowed for all stakeholder views to be
expressed and examined in a nonjudgmental forum where ethical principles were applied.
Another measure of success is that patient values and quality of life were also considered in this
process.

Rationale: I believe that the ultimate rationale for an ethics consult is to improve the quality of
patient care. This process can also remove or reduce moral distress in staff as well as patients
family members. It is important to help the family distinguish the patients wishes from their
own desires, and the ethics consult is the best way to address this. This process also has a
considerable influence on facilitating the patients autonomy; in addition, it provides moral
support to staff and family members (Geppert, 2012, p. 383). Other important considerations

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addressed by an ethics consult include both patient and staff satisfaction. According to Fiester
(2012), Without a serious response to the real or imagined ethical offenses and injuries involved
in these conflicts, patient care will necessarily remain substandard in the patients perspective;
therefore, they couldnt possibly feel satisfied with the care they have received; and
correspondingly, the needs of the staff will also go unmet (p. 4). An ethics consult, to my mind,
is the single most appropriate and helpful intervention in situations of ethical uncertainty given
that excellent patient care is ultimately the issue at stake.

I pledge to support the Honor System of Old Dominion University. I will refrain from any form
of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a
member of the academic community it is my responsibility to turn in all suspected violations of
the Honor Code. I will report to a hearing if summoned. Mary Ellen Cooper

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References
American Nurses Association, Code of Ethics for Nurses with Interpretive Statements,
Washington, D.C.: American Nurses Publishing, 2015
Fiester, A. (2012). The difficult patient reconceived: An expanded moral mandate for clinical
ethics. American Journal of Bioethics, 12(5), 2-7. doi:10.1080/15265161.2012.665135
Geppert, C. M. A., & Shelton, W. N. (2012). A comparison of general medical and clinical
ethics consultations: What can we learn from each other? Mayo Clinic Proceedings,
87(4), 381389. http://doi.org/10.1016/j.mayocp.2011.10.010
Gillon, R. (1997). Clinical ethics committees--pros and cons. Journal of Medical Ethics, 23(4),
203204. Retrieved
from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1377266/?page=1

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8
Ethics Case Study Discussion
Initial Posting Rubric
Criteria

Comment

Points

Logical concise ethical rationale

presented for decision in case
study (20)

Decision based upon an

identified ethical framework
(theory) (30)

Professional sources used to

support position/ Grammar, APA
formatting (10)

Total points Initial Post (60)

Student used own case study

(+5)
Rebuttal Rubric
Criteria
Logical concise ethical rationale
presented for rebuttal of
anothers decision in case
study.(15)

Rebuttal based upon an

identified ethical framework
(theory) (15).

Grammar, APA formatting

Use of at minimum 1 professional
source for support (10)

Total Points Rebuttal (40)

Combined Points Initial

Post/Rebuttal (105)

Comment

Points

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