Appendix 2 – Short examples to describe ethical theories
2015: Ethical dilemmas faced by professionals providing dementia care in care homes and hospitals
Each of the following vignettes/short stories reflects a different ethical theory or approach to an ethically challenging situation. We have based them on different people and different situations to those already described in the pubilcation so that you can reflect on a broader range of situations and potential ethical dilemmas.
Mary has been a resident in the nursing home for four years and she now has severe dementia. For some years she has been plagued by urinary tract infections and it has been difficult more recently to find antibiotics which work because the bugs have built up resistance. She has now had two quite bad chest infections. On both occasions she has been taken into hospital from the nursing home. On both occasions it has not been possible for staff to do anything therapeutic for her because of her marked agitation. She gradually improves back in the nursing home, but she has now developed a further chest infection and seems to be very ill. There is a worry that she might die, but she is not accepting medicines by mouth and she remains agitated. A decision has to be made about whether or not she should be taken into hospital. The staff involved discuss amongst themselves and with the familythe consequencesof the different options and decide that nothing would be achieved by a further hospital admission that could not be achieved in the care home with familiar staff in familiar surroundings. It seems quite likely that her wellbeing or welfare will be maximised by her staying in the nursing home, rather than being admitted to hospital again, so this seems the right thing to do.
Mrs Martin is known always to have been a very proud lady who was careful with her appearance. She now has severe dementia. Her personal hygiene has been deteriorating. She eats her food in a very messy way, which leaves stains down the front of her blouse. She is also sometimes incontinent of urine and occasionally of faeces. She refuses to wear pads of any sort. She hates any form of personal intervention. She becomes very agitated and physically aggressive when staff try to bath her or to change her clothes. They have, therefore, adopted a policy of tolerating her poor personal hygiene. However, there comes a point at which her smell and appearance are upsetting for other people. Moreover, her family can confirm that she herself would never have wished to be seen in such a state. The care home, therefore, work out a care plan underpinned by their perception of their duty of care. They recognise that they have a duty to respect Mrs Martin’s autonomy, but they are concerned about her dignity and the risk of infections if her personal hygiene is not attended to at some point. So, on the basis of duty, they agree amongst themselves and with the family that they will intervene and provide personal care when there is faecal or urinary incontinence. They will also change her clothes at least once daily and make sure that she has had a bath at least once a week. Part of the reasoning is that the staff feel that they would wish to be treated this way themselves and, therefore, they feel they havea dutyto treat Mrs Martin in a similar fashion.
The rights-based approach
Albert loved to walk around the nursing home garden and get some exercise, but owing to his balance problems he needed a walking stick. He tended to forget this and last week he fell and broke his arm. He said he was trying to catch a cat that he thought he had seen. Some staff in the care home felt that Albert should now not be allowed out into the garden on his own but this meant that Albert would sometimes become upset because there were not enough staff to take him out when he wanted to go. He said that he understood that he might fall over but he said he would be more careful. Although some staff were not convinced by this and thought it would be unsafe, the majority view was that Albert had a right to take risks and a right to do what he wished to do, given that this was not harmful to anyone else and given that it was important for his quality of life. Therefore, it was agreed that he should be allowed to go into the garden, but that staff would always make sure that when he did so he had his stick with him and he would be reminded that he needed to keep his stick on him the whole time he was out. The staff were able to make this into a sort of joke with him. But the important thing was that he was not restricted or deprived of his liberty and, despite the risks, hisrightto self-determination, at least to this extent, was upheld.
The fairness approach
The Oak Tree Nursing Home organizes weekly tours for residents and tries to give everyone who has some degree of mobility the opportunity to go out in the rented bus. They usually go down to the seaside, which is close by, for an ice cream. Sometimes, however, the number of staff available to help with these trips is very limited. In that case, they can only take one or two of the residents. They usually tend to take the more mobile residents on these occasions. For the sake of fairness, however, the senior carer keeps a register of who goes on the trips and tries to make sure that the outings are distributed evenly amongst the residents. Some residents require extra staff, but the aim is that all residents should get out, insofar as this possible, an equal number of times.
The common good approach
Elizabeth is a smoker and when she was admitted to the nursing home she couldn’t break this old habit. It was forbidden for her to smoke in her bedroom and, because of the health risks posed by “passive” smoking, she was also not allowed to smoke in the lounge. The staff understood, however, that Elizabeth felt better when she could smoke as she had always done in the past. So provisions were made for a protected area to be constructed in the garden just outside the door of the care home where Elizabeth could go to smoke. In this way, she was not restricted in what she could do, but the common good of all was kept in view. It could be said that this was an inconvenience for Elizabeth, but the staff made sure that the shelter in the garden was well protected from poor weather and they always made sure that someone was free to go with Elizabeth when she went for a cigarette so that she was not lonely. The key principle, however, was that thegood of the overall communitywas maintained in an amicable fashion.
The virtue approach
Lately, Simon had been talking about his parents and saying that they were waiting for him to visit them. He would insist on the need to leave the nursing home to return home. Staff felt that it was wrong to lie to him and wanted to be honest with him, but they knew that Simon really believed his parents were alive and they felt that telling him the truth would be very distressing. Therefore, when Simon talked about his parents as if they were alive, the staff would tactfully divert his attention to other current issues in his life and avoid having to tell him directly that his parents were dead. In this way, they were trying to avoid telling him an outright lie, which would have been dishonest, but at the same time they were showingthe virtuesof compassion, fidelity and practical wisdom.
Last Updated: Thursday 26 November 2015