An son also agrees with the decision made by


An advanced practice nurse (APN), will be faced with
different types of ethical-legal dilemmas that in most cases will require the
APN to make urgent decisions that will include both moral and ethical
attention. Ethical dilemmas are conditions that have to scenarios course of
actions to take that will contradict each other (Westrick, 2014, pp 258-265).
The APN will have to choose between the two urgent decisions because each of
these choices is deemed to be equally right and urgent. This is the reason that
makes dealing with ethical-dilemmas very stressful for the APN and other
experienced caregivers involved.  It is
very noteworthy that an APN has many medical responsibilities to provide care,
and are also in the position to make urgent medical decisions that is
independent because of being the person in authority at that time. Many of the
existing ethical dilemmas will fall in with a variety of treatment withdrawal
vs maintenance, the quality of life vs the quantity of life, euthanasia vs
non-euthanasia, and pro-choice vs pro-life (Westrick, 2014b, pp.77-83).

This paper will address the ethical dilemma of informed
consent vs the right to refusal of treatment by the patient. I will show the
patient’s autonomy, human rights, informed consent, and refusal will be writing
about (Appelbaum, 2007).  Informed consent
can be described as a situation where a patient beyond question is informed and
participate in the decisions that are being made on the patient behalf while on
the other hand informed refusal, happens when the risks appertaining to a
certain mode of treatment or the treatment itself are rejected based on the
risks they pose to the patient’s health and well-being in general (Appelbaum,
2007). In such a case, the ethical aspects of deontology and consequentialism
are to be explored before the process of decision making commences.

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The ethical dilemma for this paper will involve a
seventy-year-old man that is admitted to the hospital and is currently
experiencing an ischemic attack. The patient is still in sound mind and can
make his own decisions but has exhibited characteristics of continuously
becoming weak and cannot effectively swallow after being affected by the
stroke, and so he is very uncooperative when it comes to taking treatment. His
power of attorney, who is his son has agreed to a Percutaneous Endoscopic
Gastrostomy (PEG) through phone but the man declines the PEG tube insertion
because of the health risks posed by these tubes and prefers to have homecare
with hospice. He does not want to contract ventilator-associated pneumonia as
he is well informed of the health risks these tubes have on patients. The
assessment done by the nurse indicates that the patient can make his own
decisions. Additionally, his son also agrees with the decision made by the
patient. From the ethical perspective, the consequentialist theory and
deontology can be applied in the decision making of this case. According to
deontology as Bingham (2012) puts it, an emphasis is placed on some actions as
being inherently wrong or right based on what an individual ought to do as per
their obligations and duties without considering the outcome. The
consequentialist theory, on the other hand, looks at the consequences of the
actions and chooses one that yields the least bad and the best. Legally, the
rights of the patient, in this case, are protected by the Patient’s Self
Determination Act of 1990 given the fact that he is in a position to make his
own decisions (Hamric et al., 2013).

The violated principle or ethical theory, in this case, would
be the theory of consequentialist and that of deontology if PEG tube insertion
is done. Consequentialism can be used to justify ignoring the patient if the
outcomes of the decision are to cause more bad than good. Also, the Patient
Self Determination Act of 1990 which includes the patient’s right to refuse
being treated if the patient has been determined to be able to make his own
decisions. The offences would thus be a tort of battery if a procedure is done
on the patient without their consent.

The Applied Legal Principles and Related Case

For a consent that is legally valid, the decision making
capacity is a very important condition. The right of treatment refusal and
consent laws is underpinned by the respect for autonomy principle. Dealing with
a patient without their consent is a criminal offence referred to as the tort
of battery or assault (Bingham, 2012). The decision made by a competent patient
that has been determined to be in a position to make their own decisions has to,
therefore, be respected regardless of whether or not it seems irrational or

The related real case in this patient’s situation is that of
Lane v Candura (1978), where Candura was a 77 year old widow that suffered from
gangrene in her lower right foot. Her physician recommended that the leg be amputated
but she failed to consent to that decision (Relman, 1978). This forced her
daughter Lane to file a petition in court with an aim of being appointed as an
authority on her mother’s behalf in order that she consents to the amputation
procedure. It was established by the court that Candura was in a position to
make her own decisions and so her leg was not to be amputated unless she agrees
to it (Relman, 1978). In my case above, the patient is in a position to make
his own decisions and is even supported by his son who happens to be his power
of attorney.

Legal and Ethical Reasoning and Solutions to the Ethical- Legal Dilemma

Usually, legal reasons are derived from the law while moral
reasons are as a result of moral reasoning or the results of a moral conflict
deliberation. The two have been established to generate broad unending
discussions and usually enhance decision making that is autonomous according to
the patient’s human rights (Blair, 2015). They are also the genesis of all
ethical dilemmas in advanced practice nursing. Dilemmas occur when the nurse is
forced to respect the autonomy of the patient even if the decisions that are
being made by the patient could result in serious damage. In this case, it can
also be argued that the patient’s decisions have to be ignored because the
results of the patient’s decisions are extremely harmful. It is however not
ethically right for a nurse to override the decisions made by a patient that
has been established to be competent enough to make his own decisions.
According to Oliver & Jochen (2011), nurses are obligated to respect the patient’s
autonomy and one of the ways in which this can be done is by acknowledging that
they have the right to act on their health as they please based on their
beliefs and values. An advanced practice nurse should, therefore, include the
patient’s perspective in their analysis of the conflict there is between
ethical principles has to be considered.


One of the recommendations towards the resolution of moral
distress for nurses could be the involvement of the patient’s family, explain
to the patient clearly the benefits and risks of the procedure in place so that
the patient makes a decision from a well-informed point of view and lastly a
multidisciplinary team has to be put in place to work alongside with the nurse
so that the moral distress is significantly reduced by the help rendered by the
team during decision making.


In conclusion, it is noteworthy that thorough training on
ethics and legal principles are paramount for all advanced practice nurses as
it governs all their decision making scenarios when dealing with patients. The
knowledge is also important as it enables the nurses to respect the patient’s
rights while identifying the moral conflicts and issues at play in most cases.