Paternalism Case Summary

Ethical issue

The ethical issues that surround the case study is paternalistic behavior shown by the medical staff in putting pressure to the patient’s family member to donate blood. Paternalism definition was developed by Gerald Dworkin and consist of three major features: it involves an interference of the autonomy of the person subjected to the paternalism; the omission is done without the consent from the person interfered with; and the interference is done in order to benefit the person interfered with.22 These three qualities of paternalism are clearly shown by the medical staff in the case study.
First, the medical staff ignores the autonomy of the patient’s family in making decision for not donating blood for the child. Autonomy,

means that patient is able and allowed to make his or her own choices, decision and preferences.22 Most children do not have decision-making capacity and therefore require an attorney in which usually a family member will act as a proxy.23 So, in this situation, where the child’s condition is deteriorating and the child is too young to make a decision, the parent is legal to be the child’s surrogate decision makers.23
Having a capacity to make a decision, means a surrogate decision maker cannot simply understand the situation. They need to balance between the best interests of the child and other implication such as the chances of survival, the pros and cons of treatment, evidence concerning long and short-term medical side effect of the treatment and long-term implications on the child quality of life.23 But, parents can lost the ability to be a decision makers for a child if the parents are lack of decision-making capacity, or there are irresolvable disparities between parents regarding the child’s care, or parents have clearly abandoned the child or a legal guardian has been assigned.23
There will be time when parents have conflict of interests that undermine their ability to choose the best interests of the patient such as considerations for the well-being of unborn child like the pregnant mother in the case study.23 Hence a standard of “reasonableness” should be applied which take into account of all issues that influence the situation and affirms that the best choice is one that most rational people of goodwill would choose.23 There are times where child best interests may be ambiguous, due to uncertainty on the consequences of the outcome whether it is likely to be promising or threatening.23 In emergency circumstances, and pending clarification of the situations, the assumption should be in favor of either life-saving or life-sustaining treatment.23 But, when it is possible to suspend or delay acute treatment, such a delay is fortified while waiting for the issue to be clarrified.23
Secondly, the medical staff does not ask for consent from the patient’s family to donate their blood, but instead they force the family member. Again, autonomy principles have been bridge by the health professional in the case study. Informed consent is the most fundamental aspect in medical management and it helps to promote patient centered care in health setting.24 Patient centered care are defined by The Institute of Medicine (IOM) as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions”.24
The medical staffs supposedly inform the family members of the patient about the treatment and blood donation in terms of the procedure, benefits, risk, alternative treatment and cost.24 By doing this medical staff might be able to clarify some information with the family members and hopefully makes them to change their mind to donate blood for the child. Neglecting this matter can result in patient and family dissatisfaction and poor outcomes in treatment.
The last features in paternalism is the interference is undertaken in order to benefit the person interfered with.22 In order to treat the child, the medical staff neglects the parent autonomy as surrogate decision maker and pressed the family member to donate blood without inform consent. In addition to safe the child life, a staff member was considering donating blood, although her last donated 3 weeks ago. These situations clearly show the discrepancy between autonomy and beneficence principles.
Beneficence, is define as doing good or dictates the patient’s wellbeing.25 It is demanded to be one of the moral attitude characteristics.26 Beneficence comprises the balance between one own welfare and the welfare of others and it can be divided into morally required or morally discretionary.26 The boundary between these two beneficence actions can be difficult when it comes to the general relationship towards those in need.26 But it is obvious which beneficence action should be use for relationship of special responsibility such as between nurse and patient.26
In the case study the medical staffs are responsible and morally required to treat the child. However, in a situation where the action of beneficence can be harmful to the medical staff such as in the case study where the medical staff are at risk of develop iron deficiency anemia27 if she donating blood so soon; once it does that it becomes discretionary.26 It is essential to take moral importance and its effect on welfare into thought when conflict arises.26 Medical staff are responsible to offer patients with competent medical treatment and ought to protects the patient rights and do their best to promotes the patient welfare but no more than that.26
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Explanation of the disease and the required treatment to a patient and/or their family
The family’s unwillingness to donate blood might due to lack of information sharing between the medical staff and the family member.

Therefore a discussion should be held between these two parties. In order to explain to the family member about the disease and treatment, medical staff should have good communication skills so that the intended information can be delivered effectively to the family member. Studies show that the patient health outcome can be enhanced with good physician-patient communication.28
Effective communication employs a positive influence towards patient’s emotional health, functional, symptoms resolution and pain control.28 Physician should cover a wide range of question while taking a history, including the patient’s feeling and their concern.29 In this case, medical staff should encourage family members to ask questions and participate in the decision-making about the patient management plan.28 By doing this, family members will feel themselves to be important and appreciated.29 Therefore, may influence the family members to be more likely to agree with the blood donation and treatment

plan.
Medical staff should use simple words while trying to explain the situation to the family and avoid jargon as this is hard to understand.29 Simplified word should be used especially amongst those with lower literacy level so that they can comprehend the information better. The case study is undertaken in Tanzania which consist of 158 ethnic groups that use varieties of dialect such as Nilotic, Tigota, Langi and many more.30 Therefore, health professional might require an interpreter to communicate with the patient for effective communication and to avoid misunderstanding.31
The family values, beliefs, preferences and expectations also play a great role in decision-making and should be acknowledged and addressed sensitively when considering the best interests of a child.23 This is important as it will make it easier to build trust and rapport with patients and their family members and to avoid any misinterpretation.29
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Conclusion
In a nutshell, communication skills are really important in delivering information to patients and their family.

Effective communication is essential in making a correct diagnosis, developing rapport and trust and determining proper treatment and achieving best clinical outcomes for the patient.31 Good communication skills also can avoid any misunderstanding between medical staff, patients and family members. The medical staff in the case study should discuss about the patient’s condition and treatment plan with the patient’s family. It is important for health professional to share decision making with the patient and their family members so that they will feel more appreciated, and ensure their satisfaction towards health care facilities. In making clinical decision, it is fundamental to take consideration of different factors such as patient’s culture and backgrounds. Each decision-making should be based on ethical consideration and taking into account the four principles of medical ethics, which are autonomy, beneficence, non-maleficence, and justice. Yet, to integrate these 4 pillars in a decision-making is a complex proses that requires consideration of various aspects and

elements.