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The First Steps Articulate the conflicting courses of action that appear to be required by the situation, and then evaluate whether they are

really at complete odds with each other. Is there a way that differing needs can be simultaneously met by a well-chosen action?

Assuming that one course of action must be chosen and it is in conflict with the other choice, rate the urgency of each and examine whether one argument appears to carry more moral weight than the other. In this case example, the two conflicting courses of action are represented by the nurse practitioner's requirement to treat her patient, John, with expected professional and legal standards of confidentiality, versus the NP's duty to warn her patient, Susan, about possible HIV infection.

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Ethical Dilemmas

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Principles One approach to resolving ethical dilemmas is to examine the underlying principles embedded in the case. Autonomy

(respect for people), beneficence (the duty to do good), nonmaleficence (the duty to not cause harm) and justice (fair allocation) are the principles often cited in ethical deliberations.10

In the United States, autonomy is often considered a stronger principle than the others. But in different cultures, autonomy is less valued. For example, we believe that a patient has a right to know that he or she has a terminal disease, even if this knowledge would cause the patient significant distress or even harm. Other cultures may favor beneficence over autonomy, and this is illustrated when decisions are made for patients, "for their own good." Bioethicists call this medical paternalism.

Outcomes Another ethical approach is considered utilitarian. It involves examining each course of action for the expected outcomes

and determining which action produces the greatest good.

Clearly, the case of Susan and John involves the possibility of untreated HIV infection in Susan. Concealing knowledge of John's HIV status prevents Susan from making fully informed choices about continuing or terminating the early pregnancy. These choices can minimize or maximize the potential for vertical transmission to the fetus. On the other hand, protecting John's confidentiality compromises more than just Susan. Many would argue that we have a responsibility to protect the fetus as well.

Examination of Prior Cases Ethical deliberation often focuses on examination of prior cases that contain similar competing claims. A well-known case

involving the duty to warn versus confidentiality is that of Tarasoff v. the Regents of the University of California.11,12

In this case, the moral and legal claim of patient confidentiality was upheld, resulting in an avoidable and foreseeable death to a second party. The California Supreme Court ruled that health care professionals have a duty to warn in certain circumstances, and that this duty can override how absolutely health professionals are bound to legal and professional demands of confidentiality.

Susan and John The professional and legal obligations of confidentiality, rooted in the principle of autonomy, are not easily overridden. In

the case of Susan and John, continued deliberation weighs increasingly in favor of a duty to warn and inform Susan.

Before overriding patient confidentiality, Karen should inform her practice manager, any consulting physicians and her malpractice carrier of her decision. She may also be able to discuss this decision with John in a way that provides for his continued support in what will be a difficult process for him. If Karen decides to terminate her provision of health care to John, she should first assess him for safety and provide appropriate referral for care.13

Clair Kaplan is a women's health nurse practitioner who is an assistant professor at Yale University in New Haven, Conn.

References 1. Foulk GJ, et al. The perception of ethical dilemmas in clinical practice. Int J Appl Philos. 1998;12(1):79-87.

2. Laabs CA. Moral problems and distress among nurse practitioners in primary care. JAm Acad Nurse Pract. 2005;17(2):76-84.

3. Peterson M, Potter RL. A proposal for a code of ethics for nurse practitioners. J Am Acad Nurse Pract. 2004;16(3):116- 124.

4. Milton CL. Professional values in nursing ethics: essential or optional in the global universe? Nurs Sci Q. 2007;20(3):212-215.

http://nurse-practitioners-and-physician-assistants.advanceweb.com:80/article/ethical-dilemmas-2.aspx?CP=2 Go AUG SEP OCT

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5. Armstrong AE. Toward a strong virtue ethics for nursing practice. Nurs Philos. 2006;7(3):110-124.

6. Begley AM. Facilitating the development of moral insight in practice: teaching ethics and teaching virtue. Nurs Philos. 2006;7(4):257-265.

7. Redman BK, Fry ST. Nurses' ethical conflicts: what is really known about them? Nurs Ethics. 2000;7(4):360-366.

8. Breier-Mackie S. Who is the clinical ethicist? Gastroenterol Nurs. 2006;29(1):70-72.

9. Swetz KM, et al. Report of 255 clinical ethics consultations and review of the literature. Mayo Clin Proc. 2007;82(6):686-691.

10. Fiester A. Viewpoint: why the clinical ethics we teach fails patients. Acad Med. 2007;82(7):684-689.

11. Tarasoff v Regents of the University of California, 551 P2d 334 (CA Supr Ct 1976).

12. Felthous AR. Warning a potential victim of a person's dangerousness: clinician's duty or victim's right? J Am Acad Psychiatry Law. 2006;34:338-348.

13. Smith JA. Terminating the provider-patient relationship. Nurse Pract. 2005;30(5):58-60.

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