Dealing with ethical dilemmas: nurses regularly face ethical challenges in their practice. Does their undergraduate education prepare them well enough for such challenges? One nurse educator thinks not.

Adolescence and adulthood are elastic concepts, judging by the inconsistency around when a person of a certain age can do what. You can give medical consent when you're 16, but you can't vote. You can be charged with murder under the Crimes Act when you're 14, but you can't get married without your parents' consent. You're deemed able to give sexual consent at 16, but you can't legally buy alcohol.

With such confusion, it is little wonder nurses caring for adolescents can face many ethical dilemmas related to that care. And it is these ethical dilemmas that intrigue and challenge paediatric nurse and now nurse educator Porcelina Spring. She is one of the presenters at a one-day conference organised by NZNO's Children and Young Persons of Aotearoa Section, to be held in Nelson on October 31. The theme of the conference is Envisioning the future of child health in the 21st century: How can child health nurses respond to the challenge?

An ethical challenge

The title of Spring's presentation is "Autonomy: An ethical challenge in adolescent health" and it looks at the increasing challenges nurses in this practice area face, as adolescents become more outspoken in health care settings and attempt to proclaim their autonomy. The presentation aims to provide education and advice on maintaining ethical practice, while taking into account the possibility that adolescents are competent to make their own treatment decisions. Spring, who graduated from Manukau Institute of Technology in 2000, has specialised in paediatrics. She believes not enough time is devoted to ethics in undergraduate education but says there is now a growing recognition of this need. "At Nelson Marlborough Institute of Technology (NMIT), where I work, there are 75 hours of law and ethics in the second year. From my experiences and from situations I've seen nurses having to deal with, I know there is a real need for more ethics education."

She teaches in the foundation nursing course and first-year students and is loving it. Her own interest in ethics was piqued by her first ethical challenge, which arose when she was nursing adults. "I was looking after a woman whose histology results were positive for malignancy. She kept asking me 'Are my results back yet?' I knew the results and felt stuck in a real bind, as it was the doctor's responsibility to tell her the results but that hadn't happened. All the issues arising out of that situation got me very interested in how nurses respond to ethical challenges."

Nursing adolescents is an area fraught with ethical challenges. Internationally, adolescence is generally accepted as starting at 12, but at what age this stage ends is again the subject of some confusion. "One could argue from a medical perspective that someone is an adult at 16, if they are no longer accepted into paediatric wards and are able to give consent for treatment. Yet in the general population, it is more likely to be accepted as 18, when the adolescent leaves school or can marry without parental consent," Spring said.

Adding to the difficulties facing nurses caring for adolescents is the fact that in paediatric nursing, the nurse is not only caring for the child or the adolescent, but also for their family. The nurse is expected to advocate for both the child or adolescent and their family. If there is a conflict between an adolescent and their family over treatment, then the nurse must respond. "The area where I experienced this sort of conflict most often was in palliative care. Often the families were in denial. The adolescent had come to terms with the fact she was going to die before the family had come to that acceptance. The particularly difficult situations were where the family wanted treatment to continue." So how were such situations resolved? "It was always hard. There was always a [or of talking and encouraging and helping the family along the path towards coming to an understanding of the situation. A nurse has to give them the realities without being harsh and the nurse also has to take their grief into account. It was always rewarding to help get a family to the stage where they could say goodbye. But sometimes such situations don't get resolved before death." Consent for treatment is another situation of potential conflict between an adolescent and their family. "It is important to see where all the parties are coming from, their motivation and the underlying reason for their position. Is it based on a religious belief? Have the parties all the correct information and has it been explained properly? So often it falls to nurses to make those explanations in a way that people can readily understand."

She stresses that legally those under 16 cannot give consent for treatment but refers to "Gillick competence". A legal case in Britain in 1985 concerned a teenage child's right to consent to medical treatment without the parents' knowledge. (1) The common law case established that a child under 16 who is deemed "Gillick competent" by a doctor can give consent for medical treatment. (2)

She refers to studies which have revealed differences between girls and boys in emotional autonomy and how parenting style influences the development of emotional autonomy and thus young people's ability to achieve independence and make independnet decisions. She sees these as important in helping nurses understand the range and complexity of the ethical issues involved.

Describing herself as having a "utilitarian approach" to ethical dilemmas--put simply, the greatest good for the greatest number--Spring says she has been "totally captured" by the ethical challenges in nursing. She has completed a diploma in professional ethics from Auckland University and next year will embark on a master's in philosophy through Massey University. Her thesis will focus on autonomy in adolescence. "There are a number of European studies but no Australasian studies and I would love to do research specific to our population."

References

(1) Gillick v West Norfolk and Wisbech Area Health Authority [1985] 3 All ER 402 (HL).

(2) The Ethox Centre Medical Ethics and Law Teaching Materials Handout 6: Consent and patients less than 18. http://www.ethox.org.uk/educaiton/teach/Consent/consent6.htm. Retrieved 23/06/06.