ANGELES UNIVERSITY FOUNDATION

Angeles City
College of Nursing
MEDICAL SURGICAL NURSING
LABORATORY
(NCM 0112 RLE)

FIRST SEMESTER A.Y. 2021 – 2022

CASE REPORT ANALYSIS

Submitted by:
BSN III-A, Group 4

Advincula, Vinze Patrick Maniacup, Maria Czarina

Capuno, Kristine Michaela
Guevarra, Kate Leslie
Jaring, Hanz Stephen
Macapagal, Jaymi Joy
Ong, Nia Frances Heissa
Salvador, Katreena
San Pedro, Mikhaila Verne
Sese, Aaron Chris
Unarce, Renae Allyanna

Submitted to:
NCM 0112 Clinical Instructors

August 24, 2021

I. INTRODUCTION

Situations wherein professionals are torn between two or more courses of action
are Ethical Dilemmas. If they chose one course of action, this may lead to compromised
ethical principles that are in support of the other course of action. Health cafe
professionals (HCPs) are known to be very conscious about giving honor to
professionalism and continuously elevating the standards of their practice. In addition to
that, HCPs would always use their skills with the values of justice, truthfulness, honesty,
and altruism. The value of respect is also highlighted in their field as they give
consideration to the decisions made by their clients as well as the practice of
accountability for their actions. In the medical field, rapport is very significant to be
established in a HCP-patient relationship in order to achieve the health goals in the best
possible way and this could be achieved by the application of the following ethical
principles: veracity, confidentiality, justice, beneficence, no maleficence, and autonomy.
The said principles are observed in a healthcare organization to maintain the optimal
level of health and well-being for the patients, their families, and their communities.
Although they may sound easy, it still requires thorough analysis of the cases when
controversial situations are faced by HCPs especially with regards to disclosure of
patient information, diagnosing, and treatment for the most stigmatizing disorders like
HIV-AIDS. Along with the continuous changes in the context of technology and
advancements in the medical field, the cure for HIV-AIDS is still unknown. Moreover, the
people living with the disease are still being discriminated against in our society, and
that includes obvious rejection and criticisms being faced by the patients. The social
responsibility over cost is weighed by the HCP in sensitive cases of HIV reports as the
HCP has to acknowledge the society over the patient’s right. Furthermore, the HCP
would also need to observe his/her oath which is to maintain truthfulness in his/her field
at the same time - in every situation. With that, the paper will further discuss the
identified conflict between virtue ethics of veracity, confidentiality, and beneficence of
the third party as well as autonomy, paternalism, and non-maleficence.
INTERNAL AND EXTERNAL FORCES THAT HAVE A BEARING ON THE PROBLEM
Internal Forces:
● The patient was diagnosed with HIV AIDS.
● Instead of communicating to the HCP about his treatment plan, the Patient
requested that his positive report be kept confidential, even from his family.
External Forces:
● The wife and other family members of the patient may be put at risk and harm
because HIV is a communicable disease.
● The patient's HIV positive report was revealed to his wife by the health care
practitioner.

SPECIFIED THEORY
Deontology Theory
The morality of this theory came from its rationalization not just by experience
itself. This focuses on how people treat each other as the ends, not just the means only.
Hence, the result of their actions does not make the person right or wrong, instead, it
matters to the person who has the motives to carry out the action. With that being said,
from the case scenario, a 40-year-old male was diagnosed with HIV/AIDS. He asked
instead of the doctor not to tell his family about his condition. However, even if the
doctor knows that it is his right to withhold information from his family, the risks that his
family might occur, specifically his wife, is the doctor's concern. Therefore, the doctor
decided to tell his wife about his case.
Based on the theory, the choice that the doctor made was nothing personal
against him. As a healthcare professional, he only thought about the welfare of his
family especially since the condition is said to be a communicable disease, and even
though the doctor violated his rights to confidentiality, he still decided to disclose
information to his wife. Moreover, the doctor only followed the concept of paternalism
and veracity for the family's patient’s sake. It overrides the patient’s decision and
continues to the doctor's decision according to what the doctor thinks will be better for
the safety of the people who surround him.
 On the other hand, there is some way that utilitarianism comes into the scenario.
The actions suggested that they should be outweighed by their consequences.
Utilitarianism, by definition, the moral theory refers to the outcomes or predicted
outcomes despite the action being right or wrong. Hence, the disclosing of the
information to the patient's family brought more positive impact on them; however, the
patient itself may suffer from self-crisis, anxiety, and embarrassment due to the
condition it has. On the other hand, the result of what the doctor did does not justify the
means, instead, it gives justification on how he rationalizes the situation which is morally
obligatory regardless of their consequences for human welfare.

CONCEPTS & PRINCIPLES:

AUTONOMY
Patient Autonomy refers to a patient’s right to make decisions regarding their
treatment or medical care without being influenced by the Health Care Provider or
family members; decision is free from coercion, persuasion, or manipulation (AMA J
Ethics, 2016). Respecting the autonomy of patients entails recognizing that the patients
with decision-making ability have the right to make their own decisions about their
health, even if those decisions may contradict with the advice of the physician.
PATERNALISM
The physician knows what’s best for the patient’s medical situation and there are
times wherein, they believe that their decisions are in the best interests of the patient.
The Center for Health Ethics in the University of Missouri (n.d.) mentioned that
paternalism in the healthcare context happens when a physician or other healthcare
practitioner makes choices for a patient without the patient's explicit permission. For
most of what happens in healthcare, it is unavoidable that providers would act
paternalistically in an unintentional and harmless way.
BENEFICENCE
According to Varkey (2021), the principle of beneficence entails a physician's
obligation to act in the patient's best interests, and it underpins a set of moral guidelines
for protecting and defending others' rights, preventing harm, removing conditions that
will cause harm, assisting people with disabilities, and rescuing people in danger. The
principle advocates for not just preventing damage, but also benefiting and promoting
the wellbeing of patients.
CONFIDENTIALITY
This separates or modifies any identifying information that the only restive person
could only have access to (Allen, 2017). The patients and the significant others have the
right to know the information and facts only within the required details from the
healthcare professionals. Furthermore, the only ones who can have access to the
information of the particular patient are those who are directly involved within the
treatment of the patient.
VERACITY
According to Amer (2019), veracity includes the accuracy and comprehensive
transmission of information to the patient and its significant others. It has the principle of
truth-telling that is related to disclosure and confidentiality. Moreover, this is closely
connected with autonomy at the same time. However, this principle may have a
case-to-case basis in a healthcare setting, as there are times disclosing the truth
information may harm the patient which is referred to as a therapeutic privilege.
NON-MALEFICENCE
This principle gives the obligation to the physician to prevent harm to their
following patient. Furthermore, their responsibilities are to relieve the suffering of their
patients by using the respective drugs for them including the opioids that override the
foreseen but does not have the intention to produce harmful effect or outcome.

FOLLOWING PROBLEMS STATED IN ACCORDANCE WITH THE CASE REPORT

The first dispute arose when the patient learned he is HIV positive, he then asked
not to divulge the information to his family and other health care providers. But what
transcribed on the HCP’s mind is the patient’s confidentiality as well as the patient’s
family and especially his wife’s safety, which could pose a greater risk on the
community. With this predicament the HCP got disorganized and reassessed the
literature to arrive at a verdict. Eventually, HCP still reported the outcome to the patient’s
wife. The next thing that has tackled our mind was the infringement of ethico-legal
considerations on the part of the patient. Whereas the principle of fidelity, veracity and
confidentiality were disregarded. In the defense of the HCP, they stated that they always
give emphasize and importance to their patients’ rights and observe the ethico-legal
prospect of profession to the advancement of clients and the society. They also stated
that HCPs are not obliged to honor and uphold the patient’s confidentiality when the
safety of the society is at risk, and beneficence should be always analyzed by its risk
and consequences. From the patient’s point of view, he was afraid to disclose his state
as it will segregate him to the community and he may get defamed and attacked by the
backlash from his family. People Living with HIV (PLWH) are often traumatized by the
negative behaviors from the society and their surroundings, because in our culture HIV
is commonly caused by immoral deeds and has a high transmission level.

II. PRESENTATION OF THE CASE

OUTLINE OF FOCUS

● A 40-year-old man arrived at the emergency room.

● He complained about his lack of appetite, sudden weight loss, decreased activity,
tiredness, and mouth ulcers.
● The doctor requested that all baseline investigations should be sent to him along
with HIV diagnostic tests.
● After the findings were obtained, it was revealed that the patient was suffering
from HIV in which the doctor himself informed the patient of this report.
● The patient desired to keep this information from his family and other healthcare
providers.
● Instead of speaking with the doctor about the treatment plan, the patient
requested that this information should be kept private.
● If the health care provider solely considers the patient's right to confidentiality,
there is a larger chance that his family (wife) may become infected with the same
condition, as HIV is a contagious disease.
● In the end, the HCP informed the patient's wife of his HIV positive status.
DESCRIPTION OF PROBLEMS AND HOW THEY EMERGED AND PERSISTED

● Autonomy
- This is an important aspect in the healthcare setting. It is defined as the client’s
capacity to decide for themselves based upon freedom and absence of deceit,
duress, constraint or coercion. In the case, the problem that arose was the
rejection of the health care provider on the patient’s request in keeping his
diagnosis of HIV AIDS from his wife. Although there are some cases where
autonomy is violated, especially when the decision may cause danger to others.
● Paternalism
- A healthcare provider may decide for the patient when they believe that their
actions would lead to a better outcome. Exercising paternalism was present in
the scenario, the physician was torn between the two decisions and decided to
choose what he thought was right, which is disclosing the client's medical
diagnosis of HIV to his wife. The action may seem heroic, however, the patient’s
decision making was interfered with by the doctor.
● Beneficence
- Analyzation between the risks and benefits has been the major basis of this
principle. The client may be treated differently by his own family or the community
he lives in, this may lead to ineffective coping and mental health problems. But
the action of the health care provider of telling the husband’s condition to his wife
is very much appropriate since HIV is considered as a communicable disease
and hiding the information from the wife, who may be acquiring the disease as
well, may be in danger and must be given prevention and treatment as soon as
possible. There may be negative effects on the husband, yet the benefit of saving
a life and even a family is very important.
● Confidentiality
- There is a doctor-patient relationship that includes what they have talked about
must remain confidential and private to both parties especially if it is made upon
the patient’s request. Every health-care agency has standards and procedures in
place to keep all cases confidential until the patients express their permission to
share their information and data for further implications (Aroca, 2016). In clinical
 and research contexts, all cases should be kept confidential and protected by
law, according to the literature examined. In this case, since HIV is a
communicable disease, the nature of keeping the cases private should be
evaluated in terms of the repercussions and likelihood of harm, and was violated
by the physician (Nadeem, 2020). Thus, the communicable diseases control
program advises health care organizations around the world to notify the
occurrence of highly infectious and life-threatening diseases to their local health
authorities for immediate treatment and prevention. This decision by the
physician could have broken the trust of the patient but will result in betterment
and protection of the others.
● Veracity
- The idea of truth telling, which is strongly linked to transparency and
confidentiality, as well as the fact that truth-telling fits the categorical imperative,
should be universal (Amer, 2019). Being truthful isn't just a legal requirement for
HCPs; in some delicate situations, it requires us to do more than just say yes or
no; it also requires us to weigh the repercussions of lying (Liaqat, 2019). In that
case, the physician decided to be truthful to his duty. He chose to be honest
hence violating the patient’s request for confidentiality.
● Non-maleficence
- Non-maleficence is described as not hurting or causing suffering on the patient in
order to obtain a favorable outcome. It is critical for health care workers to avoid
causing injury on purpose. According to the scenario, the physician intended to
divulge the information to the patient's family when, in reality, the patient
instructed him not to. HIV-positive people who are aware of their status are
obligated to inform their sex partners (Okumu, 2020). The physician felt that by
doing so, he might prevent the patient’s wife from contracting the illness. In that
sense, the physician had the ability to harm or impair the patient's autonomy in
order to achieve good ends.
III. CONCLUSION AND RECOMMENDATION

With the aforementioned problems encountered in the case, the following are
distinct areas wherein solutions may be established in order to improve the system and
the current knowledge about probable ethical dilemmas in the healthcare field, if such
issue arises.

Respect and Consideration of Patient’s Autonomy

Autonomy is defined as the right of a person with a sound mind to decide what
should be done with his or her own body. Although autonomy cannot be fully exercised
in some cases, it is still important to take their choices into consideration. As healthcare
professionals, it is considered one’s duty to provide quality care that is geared towards
the patient’s interests and recovery (Varkey, 2020). In this case, the HIV patient should
be given control over their treatments, preferences, and choice of disclosure. Autonomy
is still considered as one of the fundamental principles in health ethics.
In order to address issues concerning autonomy, the healthcare professional
must present all of the risks and benefits so that the client may be able to evaluate the
choices themselves and choose accordingly. The healthcare provider must also have an
unbiased stance on the decision and respect the patient’s beliefs. Lastly, there should
be protocols within the hospital or district that would be facilitated by physicians and
nurses when it comes to patient disclosure (limited to identified sexual partners)
regarding communicable diseases in order to avoid the spread of infection. All of the
care given must be patient-centered and the nurse should play the role of a nurse
advocate for the patient. With these strategies, it is seen to improve the nurse-patient
relationship thus aiding in providing patient autonomy to improve quality of care (Jang,
Allerton, & Scruth, 2017).

Confidentiality

Based on the case study, the patient personally requested his healthcare
provider that he wants his condition to remain confidential even to his wife. However,
due to confusion with the HCP regarding the confidentiality, the HCP faced a dilemma
between disclosing information to the wife who is at great risk of infection or upholding
the privacy and confidentiality that the patient has the right to. Every individual has the
right to their information whether they want to maintain privacy and confidentiality or if
they want their information to be known to anyone provided that they have given
consent. One of the solutions in upholding the right to information of patients is the Data
Privacy Act, wherein, it is the law that protects all forms of information whether private,
personal, or sensitive.

Other ways to maintain patient confidentiality:

● Confidentiality policies and agreement

● Proper security systems for information may it be physically or electronically
processed
● Involving multidisciplinary healthcare team in decision making
● Respect to autonomy and patient’s decision

Guarantee Non-Maleficence

Non-maleficence is all about weighing the benefits from the risk. It is one of the
bioethical principles wherein a healthcare provider is not to cause any intentional harm
to the client. The healthcare provider opted to tell the wife of his husband’s current
health status because it imposes health risks to the wife. The reluctance of the client
may be attributed to the stigma and shame that is usually associated with HIV patients.
In order to address the dilemma seen in the case scenario, the healthcare provider may
strengthen the nurse-patient relationship in order to facilitate an open line of
communication (Varkey, 2021).

According to Hannah Jang (2017), effective communication between the patient

and healthcare provider increased patient compliance when it came to health teachings.
They are willing to understand risks and benefits more compared to when they are
reserved in communicating. The healthcare provider may lessen the stigma in order to
avoid the feeling of decreased social worth to the patient. Men were also found to be
more apprehensive when it came to HIV diagnosis and disclosure. With this, healthcare
providers are considered to commit maleficence if they allow stigma get in the way of
their provision of care and if they intentionally commit harm. Instead, a solution that
Jang and colleagues proposed was that a healthcare professional should guide patients
in making informed consent while respecting their decisions. What is important is that all
of the options were laid out to the patient prior to making a decision.

Beneficence

To build a trusting relationship with a client poses a great deal of stress for the
healthcare provider especially on sensitive matters such as HIV/AIDS. As we take
careful analysis of the dilemma in the scenario, the asking of questions begins as the
patient asks not to disclose his condition to his wife and his family. Yet, in the context of
beneficence, the HCP must act for the protection of other’s rights, prevent harm and
eliminate factors that may cause harm, and help others to achieve optimal health. In the
case scenario, while the HCP tries to give utmost respect to the patient’s request, the
HCP also puts great consideration on the welfare and safety of the client’s wife and
family since HIV is an infectious, communicable disease that could jeopardise the health
of the patient’s significant other, family, and possibly the community. The problem then
becomes, whether or not the HCP should disclose the client’s condition to the family or
uphold the patient’s request not to. But in the end, the HCP chose to tell the family
about the client’s condition.
The dilemma could have been resolved peacefully if the HCP thought about
considering to verify the reason why the patient did not want his family to know his
condition in the first place. Through the aid of therapeutic communication, the HCP may
gain the trust of the patient enough to tell him the reason. In research from Gould
(2013), therapeutic relationship dictates a good therapeutic outcome which is usually
thought reflected through responsive words and gestures. Then, after identifying the
reason as to why the patient chose to keep the case out of his family’s knowledge, the
HCP may impart health education so as to give important information about the
definition of the illness, mode of transmission, ways to avoid transmission, and diet. As
Wang, M., et.al., (2018) suggests, health education is crucial for enhancing infectious
disease prevention and control, and health knowledge and behavior are critical
components of health literacy. This way, the patient may overcome the reason why he
chose to keep his illness from his family. Through a collaborative effort with the
physician, the nurse, the dietician, and the patient and his family, the patient may face
his illness wholeheartedly with the support of his family while being aware of the
situation and protective of their own well-being.
With the above mentioned solution, the HCP would have a clear health care plan
and how to deal not only with the patient, but also the family, holistically.

Veracity

Veracity is defined as being truthful and honest, and it is connected to the notion
of autonomy. It is the foundation for the relationship of trust that develops between a
patient and a health care practitioner. Veracity is the structure that binds the patient and
clinician together as they work toward mutual treatment goals. Regarding the case
scenario, laboratory results indicated that the patient was HIV positive. Following that,
the patient requested that this information be kept confidential from his family and other
HCP. Rather than discussing the treatment plan, the patient asked that the doctor keep
it confidential. On the other hand, the HCP recognizes the patient's rights. However,
because HIV is a communicable disease, the patient's family's risk increases if the HCP
takes the patient's right to anonymity into account. The HCP then informed the patient's
wife of the HIV-positive status report. The physician decided to be truthful to his duties.
He chose to be truthful, therefore violating the patient's confidentiality request for the
sake of the patient's family.

In maintaining the concept of veracity, it is essential to communicate openly and

meaningfully, which is essential in any honest relationship between two people. The
relationship between the healthcare provider and the patient must be built on mutual
trust and honesty. Patients are encouraged to be honest about their medical histories,
treatment expectations, and any other pertinent information. On the other hand,
healthcare providers must be truthful about the diagnosis, treatment options, the
benefits and drawbacks of each treatment option, the cost of treatment, and the
duration of the various treatment options. This empowers patients to act in their own
best interests by utilizing their autonomy.
 Additionally, Thompson (2018) states that the concept of veracity's initial
application is to informed consent and the patient's autonomy to make decisions based
on all available facts. Patients require accurate information about their medical condition
and treatment alternatives. However, some patients or their families may wish to remain
unaware of the absolute reality. Additionally, lying to a patient violates the patient's
autonomy and may jeopardize future interactions with healthcare providers. Since
relationships are built on trust, lying, even small "white lies," eventually erodes trust
(Beemsterboer, 2020).
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