Nursing from 8-5: The Ethical Dilemma of Nursing within Bounds
Every year, more than 5 million people die because of injuries; of which 25% are due to road traffic crashes. It is estimated that 10 million motor vehicle crashes occur annually in the world. About 1.26 million people died in road traffic crashes in the world during 2000 and out of these deaths, 35% occurred in South East Asia (Bhatti, Ajaib, Masud & Ali. 2008). In Pakistan 2.4% deaths occur annually due to road traffic accident (Razzak & Kellermann. 2002).
However, patient survival depends on early arrival in the emergency department. Unfortunately in a developing country like Pakistan, patients are usually transferred to the emergency department either by relatives or bystanders. Even in major accidents, where no site help is available and with no pre-hospital emergency service in the country, many patients transfer late to an emergency due to which road traffic accident (RTA) mortality is high in Pakistan (Razzak & Kellermann. 2002).
I would like to describe one incident that really shook me and impelled me to write this article. In every session of my basic life support and advance support I teach my participants the importance of early and effective first aid provision to victim. But in his particular incident, I was not allowed to provide first aid.
One year back when I was travelling with my husband I witnessed a road traffic accident. A truck hit a motorcycle and both the passengers hit the road and started bleeding severely from mouth and nose. All the people on the scene rushed towards the victims, I also wanted to go but my husband, being seriously concerned about my safety was not comfortable with the idea. Since last year I have been wondering whether I am a nurse only between 8-5pm?
Reflecting on the above scenario several questions come to mind. Does it really matter that I am an off duty nurse? Is there any legal risk involved in applying nursing skills at the site of an accident? What if I try to help the victim and get accused of interfering with medical care and making the case worse because I’m not a doctor? What are some of the religious perspectives attached with the notion of Help.
After internalizing the scenario my standpoint is that one might approach this case by asking, whether their help will provide benefit to the victim? Providing benefit to patients or who is in need falls under the heading of beneficence. “Beneficence refers to an action done to benefit others” (Fry & Veatch, 2002, pg. 166). In this case taking care of an injured person or calling the ambulance would be an appropriate action of beneficence.
Walking away from the scene is morally unacceptable to the nurse. To render assistance to RTA victims is not obligatory for nurses only, but any laymen who witness it have the same liability. However, the nurse at the scene of an accident is obligated to do more than the layman as an injured person requires advanced or specialized medical skills. In this way a nurse can benefit the patient more and helps to decrease RTA related mortality.
However it is also a fact that nurses are not morally required to benefit persons on all occasion, even if we are in a position to do so (Fry & Veatch, 2002). For example a nurse is not morally accountable to perform all acts of good deeds that would benefit that victim. The International Council of Nurses’ pledge, 2012 states that “I will respect at all times, the dignity and religious beliefs of the patients under my care, holding in confidence all personal information entrusted to me, and refraining from any action that might endanger life or health.” According to the code of conduct set by this pledge, nurses are not morally or ethically obligated to assume the same level of commitment as with their inpatients but helping the victim in need is a righteous act that nurses should do.
Nevertheless, from the perspective of Kant theory, how could duty to care, be appraised? Kant states, “The moral worth of an action does not lie in the effect expected from it and so too does not lie in any principle of actions that need to borrow its motives from this expected effect” (Khan, 2005, pg.27). According to Kant, one of the principles of morality is “duty to self and to others” (Khan, 2005.pg.27). When a nurse takes an oath, she is responsible to give her best to decrease the suffering of his/her patient. By taking oath the nurse is morally bound to fulfill his/her duty.
Their capabilities might be sometimes limited, based on the situation. For example, in the above mentioned scenario a nurse might not be able to perform mouth to mouth resuscitation because of bleeding but ignoring the victim and walking away is not morally acceptable. According to Kant, for the actions to be morally worthy, nurses must perform their “duty to care” for their patient with an obligation of fulfilling a promise to their profession and towards their patient (Fry & Veatch, 2002).
However it is also undeniable that every individual must consider their personal safety first before helping others. What if a nurse helps the victim and gets accused? What if by doing cardiopulmonary resuscitation (CPR) victim does not revive and bystanders think that the nurse caused further damage to the victim? To help or render assistance to someone in an emergency refers to the good Samaritans law.
Usually if a person helps someone in an emergency, he is not obligated to help him unless society law exists. However, if law exists then going away from the scene is an act of negligence? “Under the good Samaritan laws which grants immunity, if the good Samaritan makes an error while rendering emergency medical care, he or she cannot be held legally liable for damages in court” (Sbaih, 1995, pg.9). Unfortunately there is no good Samaritans law in Pakistan (Asfandeyar, 2015); which creates a sense of fear in the helper of getting accused.
Another concept that emerges is value of human life i.e. brotherhood. Though Islam and other religions support the concept of humanity very well, we cannot turn away from social realities. A big issue in Pakistani society is gender bias; males are dominant and empowered. So if a female nurse walks away from the scene, one big reason is the male crowd surrounding victim who would refuse to let her intervene.
According to Pakistani constitution, article 25, “Steps shall be taken to ensure full participation of women in all spheres of national life.” However the reality is that women are reluctant to help others because they feel inhibited by society.
In the light of published literature and religious and legal perspectives, I consider my stance caught between ethics, moral values and personal safety. One act will benefit the victim but another will cause harm to the helper. Whereas, I believe the ultimate benefit should be provided to victim who needs it most regardless of any fear or social ambiguities.
• There is less focus on emergency healthcare in developing countries especially due to lack of pre-hospital screening facilities. If such a system could be made to recognize and transport the injured victims to a nearby hospital then it would decrease RTA morality in the country.
• Public awareness sessions should be organized by the government to impart the importance of first aid.
• Good Samaritan law should be made in the country that holds every individual responsible to not ignore any emergency.
• Women should be given a safe environment to practice their rights outside.
• Medico legal officers should be available in every hospital to perform initial formalities so that it can speed up the emergency intervention.
• Availability of ambulances in time is very important to transfer the victim.
• Instead of different pre-hospital services, an integrated trauma system should be considered as a long-term strategy with a focus on research.
Pakistan has a weak health infra- structure. This suppress individual autonomy to get medical care, especially in emergency. According to the report of 2014 Pakistan Bureau of Statistics every year 4,500 people die because of RTA in Pakistan. Studies show that half of these deaths could be prevented if victim received first aid on time. In our country people stand and make crowd but no one will step forward and render help because they have no idea what to do.
There is also a sense of fear among healthcare providers or lay rescuers of being held accountable. But if a good Samaritan law is passed in our country, it will protect all citizens who provide first aid to victim. In this way we can save more lives.
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