In considering the case of whether to give Mr. S a wander guard on his ankle, there are several ethical issues to ponder. First, it is important to assess what Mr. S’s goals are in this situation. This is an important ethical issue because it dictates how we must proceed in terms of beneficence and autonomy and deals with Mr. S’s core values. Another ethical issue to be considered is Mr. S’s ability to fully understand the potential outcomes of the situation for him, personally. This directly relates to autonomy and whether it is intact and is a key force in driving the care team’s handling of the situation. Furthermore, an extremely important ethical issue to contemplate is benefit versus harm of applying the wander guard or withholding it and which outweighs the other. This is an ethical issue in which, in addition to contributing to beneficence, two people can have completely different perspectives with neither being incorrect and also deals with the intentions of the decision. Finally, we must also reflect upon his sister’s intentions as Mr. S’s surrogate decision maker while his capacity is compromised. She holds a duty to do what is best for her brother by acting in his best interest, but is also in a position to potentially benefit from her decisions with his care. To assess these ethical issues and therefore decide the proper course of action, we must assess the situation through the lenses of beneficence, autonomy, and dignity.

Beneficence is characterized by acting to “promote someone else’s good or welfare” (Yeo 2, 103) through “preventing or removing harm, or more directly acting to produce a good” (103). Clinically, beneficence is the clinician’s obligation to intentionally do good and provide the best possible outcome for the patient, while minimizing the risk of harm and suffering. For Mr. S, it seems that the beneficent choice would be to place the wander guard. He has already suffered temporary deficits as a result of his stroke and motor vehicle accident and has fallen twice as a result of his unwillingness to walk to the bathroom with assistance. Superficially, it would seem that the most immediate way do good and prevent further harm for Mr. S is to place the wander guard. To fully make this assessment, however, we must consider Mr. S’s goal in this situation and the entire recovery process. Both seem to overlap; by refusing to use a bedpan at night and get assistance from the nursing staff to go to the bathroom, it is clear that he wishes to regain his independence. By not placing the wander guard on his ankle, Mr. S can experience further harm and injury as a result of a fall and set himself farther back from achieving this goal. Placing it would minimize harm to him by preventing future falls while he recovers and do good for him by helping him achieve his goal of becoming fully independent again. Therefore, the only decision that would support beneficence for Mr. S is to place the wander guard.

Autonomy means to govern oneself. It is broken down into 4 components: free action, effective deliberation, authenticity, and moral reflection (Yeo, 92). Free action is the ability to accept or refuse treatment, even when beneficial, as one chooses without coercion. Effective deliberation is the process by which one rationally reasons through a decision by weighing the pros and cons. Authenticity is the concept that the decision being made is consistent with the patient’s previous decisions and core values. Moral reflection is the evaluation of whether the patient’s decision aligns with their core values and is aware of how the decisions will impact themselves and others (Yeo 1, 92-95). In assessing Mr. S’s case, the most relevant aspects of autonomy are effective deliberation and moral reflection, both of which seem to be compromised. Being that his sequential reasoning is impaired and that he does not recognize that he is putting himself at greater risk for further harm by refusing help for ambulation, effective deliberation is also impaired. He also seems unable to understand that the wander guard is not analogous to a shock collar and that it is the least restrictive option, as he cannot be allowed to ambulate without assistance and hurt himself more, further supporting the impairment of his effective deliberation. Furthermore, since his ability to predict consequences of his actions and decisions using cause and effect reasoning is impaired, he cannot understand his resistance to any form of aid, either through the wander guard or staff assistance, it seems as though his moral reflection is compromised. Since effective deliberation and moral reflection are not intact, Mr. S cannot exercise his autonomy in this situation. Therefore, by way of autonomy, the best decision is to place the wander guard.

It is imperative to consider Mr. S’s dignity in this decision. Dignity is a reflection of a patient’s intrinsic and extrinsic worth and acknowledges a patient’s status as a moral being worthy of respect. A big part of respecting a patient’s dignity is respecting a patient’s values (Royal College of Nursing, 8). In Mr. S’s case, preserving dignity is accomplished by acknowledging the importance of timely toileting and respecting his right to take risks for himself. By placing the wander guard and therefore forcing him to wait to use the restroom until staff members are available to assist him by restricting his movement, Mr. S’s dignity would be infringed upon. It can be inferred that placing the wander guard on Mr. S’s ankle would greatly diminish his perception of his self-worth, thus disrespecting his dignity. Through this lens, the best solution would be to allow him to ambulate on his own and not place the wander guard.

In weighing beneficence, autonomy, and dignity, I recommend placing the wander guard. I have determined that this is the best course of action because Mr. S’s dignity can eventually be fully restored even if his present dignity is compromised by acting in favor of beneficence and autonomy. A great deal of Mr. S’s dignity sits in his ambulatory independence, and the only way to restore that is to place the wander guard. Doing so will prevent future falls and thus prevent the delay of his recovery. By preserving present dignity alone, he is more susceptible to further injury, risking even greater degradation of his dignity. Acting in favor of beneficence and autonomy, however, will move him in the direction of his goal.

 

Works Cited

Royal College of Nursing. (2008). Defending Dignity–Challenges and Opportunities for Nursing. London: Royal College of Nursing.

Yeo, M et al. (2010). Autonomy [selections]. In M Yeo et al. (eds.). Concepts and Cases in Nursing Ethics. [3rd edition] Ontario: Broadview Press, pp. 91-97, 103-109.

Yeo, Michael et al. (2010). Beneficence. In M Yeo et al. (eds.). Concepts and Cases in Nursing Ethics. [3rd edition] Ontario: Broadview Press, pp. 103-116.