Ethical Dilemmas in the Dermatology Outpatient Department in China

Introduction

Ethics is the discipline that deals with the concepts of what is “right” and “wrong” and with moral issues surrounding duty and obligation. According to Cranmer and Nhemachena,¹ philosophy is the process of examining and reflecting on the meaning of how we live. Ethics has also been considered as a dominant nursing philosophy in nursing practice since Florence Nightingale’s time.² Her proposed theories of nursing and nursing practice remain core tenets of nursing philosophy even today³ and have played a large role in promoting the rise of modern nursing and the development of hospitals.⁴ Although it is difficult to define what is “right”, understanding the meaning of ethics is an effective way to help nurses establish their professional roles and the delivery of professional care in practice.⁵ Ethics and morality are terms that share the same meaning and are often used interchangeably.

Globally speaking, sexually transmitted diseases (STDs) remain a sensitive issue within generally healthy environments.^6–8 STDs were caused by pathogens that can be acquired and transmitted via sexual activity and refer to a series of clinical syndromes and infections.⁹ It involves about 25 separate infections, among them chlamydia, gonorrhoea, and syphilis.¹⁰ In the current medical environment, different countries have developed different principle-based approaches to tackle the ethical issues surrounding STDs. According to the STDs treatment guidelines, health providers should encourage STDs patients to inform their sexual partners about their real disease, so that their sexual partners could receive timely treatment.⁹ However, in practice, persuading patients to do so really poses a dilemma for health professionals.

In China, since the early 1980s, STDs have re-emerged along with the new economic liberalisation and the open-door diplomatic policy, with the number of infections dramatically rising in recent years, even outpacing rates in the United States and the European Union.¹¹ At present, there is no provision in the criminal law for the malicious transmission of AIDS in China, but there are provisions on the crime of transmission of sexually transmitted diseases. Whoever knowingly knows that he is suffering from HIV, syphilis or gonorrhea shall be sentenced to fixed-term imprisonment of not more than five years, criminal detention or public surveillance and shall also be fined. Some scholars concluded that there were about 1.6 million cases of syphilis, gonorrhoea and hepatitis B reported in China in 2012, and it has become a notifiable disease.^12,13 A review from Wang reported that gonorrhoea cases tend to slight rise from 2014 to 2017 in China, meanwhile, it might be underestimated due to the amount of number of private clinics that do not report gonorrhoea cases in China.¹⁴ Not to mention that there is less research on patients who suffered STDs with ethical dilemma.

The author works in the dermatology outpatient department in a tertiary hospital in China ‒ a public general teaching hospital in the country’s third most populous (98,720,000) province. Currently, related ethical dilemmas were frequently encountered by doctors and nurses working in clinical practice. Whereas there were no evident ethical principles established concerning disclosure of STDs patient information to other parties within the complexity of Chinese culture. Therefore, the issue of disclosing patients’ STD information to their at-risk sex partners against patients’ wishes will be critically debated. Thus, this paper intends to reflect upon and discuss how nurses as moral agents deal with ethical dilemmas within Chinese culture and provided some orientations for further study. Initially, the author presents a case scenario. Next, the debate will be underpinned by the Corey et al¹⁵ Model to discuss how to solve the ethical dilemma. Finally, considering how to provide an ethical reference for clinical practice with STDs in the future.

Case Scenario

In this paper, we provided a real clinical case in order to illustrate the complex ethical tensions experienced by nurses when forced to contemplate breaching STD patient confidentiality.

Mr Liu (not real name), a thirty-six-year-old engineer, was a patient in the dermatology clinic of the tertiary hospital. He presented symptoms of a thick, cloudy and bloody discharge from his penis. The laboratory examination confirmed he was suffering from gonorrhoea. Alice (not real name), a professional nurse working in dermatology, informed Mr Liu that he should tell his wife, so that she could be tested and treated, but he refused. He insisted that the nurse hide his illness from his wife because it would ruin his family and his life. Alice noticed that his wife was waiting anxiously outside of the consulting room. After the consultation, Mrs Liu stepped forward and asked the nurse about her husband’s illness and the test results. The nurse was very embarrassed and did not know how to respond.

Ethic Issues and Analysis

Corey et al¹⁵ Model includes eight steps to experience ethical issue, which is an effective tool to challenge ethical dilemma, and widely used to help practitioners making ethical decisions.¹⁶ Patients are vulnerable people in vulnerable situations. Nurses, as professional and moral agents, have a responsibility for upholding specific standards during closely contacting with them according to the Code of Professional Conduct and Ethics for Registered Nurses and Registered Midwives.¹⁷ Due to lacking any relevant laws or code of conducts to deal with the ethical issue, it has become a notable ethical problem in China recently. Besides, from a moral perspective, nurses’ sensitivity, imagination, courage and competence play an active role at the heart of ethical practice that demands the development of associated skills.¹⁸ Although the following ethical practice is the overriding duty for healthcare practitioners, some challenging ethical dilemmas emerge from extraordinary situations which cannot be answered by principles alone.

This real clinical case perfectly illustrated the moral dilemma nurses faced as moral agents: should Alice maintain her ethical obligation to protect patient confidentiality, the foundation of trust in the clinical setting,¹⁹ or should she give precedence to her obligation to disclose information to those whose lives may otherwise be put at risk? Alice faced a moral dilemma that occurred frequently within the author’s workplace.

In the case of Mr Liu, the patient’s wife was not Alice’s patient, but STDs require simultaneous treatment of patients and sexual partners. Therefore, Alice, as a professional nurse, not only had to safeguard Mr Liu’s privacy but was also obliged to disclose his diagnosis to his wife in order to protect Mrs Liu from the risk of disease. The main reason for Alice’s dilemma was lacking relevant guidance and codes to help nurses like Alice make such difficult decisions. A similar study also indicates that the ethical conflict usually happened in the relationship of the patient privacy and partner notification.²⁰ It is the challenge for nursing practitioners in clinical practice.

The Impact of Traditional Culture

For five-thousand years, many Chinese people have been influenced by the Chinese philosophical principles of Confucianism, Taoism and Buddhism within their social environments.²¹ In addition, Professional Socialisation theory and Symbolic Interaction theory has informed peoples’ beliefs and leadership behaviours.²² Such philosophies emphasise harmony among individuals and do not advocate disclosing controversial information about themselves to others in society.²³ This has a considerable impact on the authors’ department within the hospital, which is the province’s biggest dermatology clinic, and has had a profound influence on shaping professional ethical guidelines. Therefore, guiding nurses in coping with their related moral distress will help nurses to get rid of the cultural constraints which had been deeply rooted in their actions.²⁴

In terms of work climate, conventionally, the status of nurses is perceived as lower than that of doctors, and, consequently, the persuasive power of doctors over patients is far greater than that of nurses.^25,26 Due to the influence of traditional culture and increasing medical disputes in China, when nurses encounter some problems, they prefer to tell patients to consult the doctor rather than taking responsibility for helping the patient to solve the problem by themselves.^22,27 In fact, nurses also played an important role in the consent process, which includes providing, supporting and ensuring additional non-medical nature for the requirements of patients is real.¹

The Relevant Ethics Codes

Ethics codes provide professional guideline for daily clinical practice.²⁸ Basically, professional nurses should follow four principles in approaching making ethical decisions and related behaviour in the clinical setting: according to Beauchamp and Childress,²⁹ that includes doing good, avoiding harm and showing respect for autonomy and justice. Relevant guideline created by Liaschenko and Peter⁴ maybe could guide Alice to deal with her dilemma in this situation. They described healthcare institutions as moral communities with various aims, some of which run in opposition to the moral imperative to obey patients’ wishes.

Moreover, NMBI¹⁷ stated that, as moral agents whose actions are underpinned by the revised Code of Professional Conduct and ethics, each nurse have a responsibility to execute professional duties to resolve ethical conflicts. Additionally, NMBI¹⁷ adds to the dilemma, setting out a code for nurses that aims to ensure patient care in a safe environment, while simultaneously ignoring the principles underpinning nurses’ professional responsibilities and obligations.

Confidentiality plays an essential role in the promotion of trust between nurse and patient.^30,31 Confidentiality requires that the trusted person cannot disclose information to anyone outside the trust relationship, because of an obligation to protect privacy.³² From the nursing leader’s perspective, this was the preferred option, as it maintains the nurse-patient therapeutic relationship of trust and good communication.³³ Also to be considered are the ethical issues widely referred to in medical ethics as outlined by Benn and Boyd: the individual autonomy of people, beneficence, non-maleficence and justice.³² The principles of autonomy and beneficence are more concerned with individual ethics, whereas justice focuses on social ethics and the formulation of criteria for solving potential conflicts between people. However, regarding informed consent, doctor and nurse both faced the dilemma whether to disclose or not because they have the same responsibility for establishing and maintaining a trusting treatment relationship with the patient.^34–36

How to Apply Ethics in Practice

Moral philosophy provides a foundation to debate the growing moral problems occurring in the nursing environment.³⁷ In philosophical ethics, utilitarianism advocates that the moral quality of an action depends on its benefit to people rather than the action itself.³⁸ Utilitarianism cites the consequences of action as determining its correctness and based on the largest group of individuals generating the most benefits, that is, the consequentialist theory produces good results through intervention.³⁹ It is also named as “Consequentialism” theory.³² Also, consideration for the trust relationship occupies a dominant position in solving ethical issues, especially in relation to STD patients, who naturally prefer not to suffer the effects of stigmatising attitudes in their lives.⁴⁰ It can ensure the safety of patients and promote targeted, good-quality care.^41,42 This is patient-centered and considers issues from the patient’s perspective, which is also a manifestation of Kant’s duty-based deontology.³⁹

Drawing on available guidelines via theory, Alice had to consider how to warn Mrs Liu, which involved decision-making. The purpose of decision-making is to select the best and most feasible way to tackle complex issues without creating additional unfavourable outcomes, as outlined by Dooley and McCarthy.¹⁹ They identified three levels of decision-making: macro level, meso level and micro level. Depending on micro level decision-making, Alice had to consider what Mrs Liu should be minimum told, according to the minimalist principle of disclosure that seeks to protect patient privacy,⁴³ as far as possible. On March 1, 2021, the newly revised Regulations of Yunnan Province on AIDS Prevention and Control clearly stipulated that HIV-infected persons and patients should timely inform their spouses or sexual partners of HIV infection; the medical and health institutions have the right to inform them.

In Mr Liu’s case, Mr Liu believed that if his wife finds out the truth of his diagnosis, his family and marriage would be damaged. Also, as the professional practitioners, the nursing leader suggested patients should have autonomy based on the principle of patient safety in the current workplace, which can make sure the trust relationship can be built. Regardless of patient’s cultural and ethnic background, gender, age, sexual orientation, nationality, illness, and disabilities, the professional nurse should give patients the dignity and rights for decent respect when they are treated as independent individuals.²⁸

When considering this situation, Alice had to maintain his trust and respect his autonomy. If Alice disclosed Mr Liu’s real diagnosis to Mrs Liu, it could have broken the trust relationship with the clinic and his family and might create far more dangerous consequences. Thus, Mr Liu had a right to decide whether to inform his wife, while Alice was obliged to safeguard his right to confidentiality.

Considering Probably Courses of Action

For professional nurses like Alice, deciding how to balance the relationship between protecting Mr Liu’s right to confidentiality and informing Mrs Liu of his diagnosis, so that she could take the appropriate action, is tough. However, good outcomes may be reached by considering all the principle involved. In this dilemma, if Mr Liu told his wife in time about his real disease, his wife could receive timely treatment. Meanwhile, Mr Liu could also avoid his reinfection after his wife had been treated. In light of the principle of justice, Mrs Liu is also a victim, and she should be informed that her health could be damaged. Therefore, the principle of non-maleficence and comes into play to protect the privacy of Mr Liu while informing third parties, in this case his wife.

Professional codes combined with utilitarianism can validly address this ethical dilemma, which nurses are often faced with it. Most importantly, nurses need to master the available knowledge relating to ethical principles, familiarise themselves with moral codes and develop relevant competencies and moral sensitivity when persuading patients to disclose.^4,44 This is the embodiment of deontology by Kant’s for professional nurses.⁴⁵ Besides, Alice could have had an in-depth discussion with Mr Liu, from the utilitarianism of view, telling him in detail about the hazards of STDs and the related risk factors. Following that, Mr Liu may have decided by himself to inform his wife about his positive diagnosis. Furthermore, based on this approach, Mr Liu was responsible for deciding whether to inform his family.

Discussion

This study shows how closely related cultural factors are to ethics and morals; philosophy helps nurses to evaluate existing problems and solve them, and, as such, can empower nurses by building confidence in their competency and giving them the ability to make difficult ethical decisions more professionally. In fact, ethical dilemmas, such as that described here, often happen in daily nursing work. Therefore, the ability to deal with them is a necessary quality for nurses. As ethical agents, nurses should respect patients’ autonomy and contribute positively to the relationship between confidentiality and the nurse-patient therapeutic relationship, so that effective communication can be established. The case of Mr Liu highlighted in this study demonstrates that, in similar situations, when protecting third parties, nurses should comply with the minimalist principle of the disclosure. It indicates that nurses should continually reflect on all characteristics of their practice and make a targeted decision where necessary, like Alice. At present, the content definition of this law is relatively vague. If the laws do not permit a breach of confidentiality then the nurse or health care professional has no choice and the ethical issues for the Healthcare professional (HCP) will be low. If laws allow a breach of confidentiality, but only vaguely specify when this is warranted the ethical dilemma is higher. Well-defined regulations, alike for all will allow easier decision-making.

Moreover, based on the Chinese cultural tradition of non-disclosure, via the Corey et al model, this study recommends the creation of a professional code supported by government policies to assist health professionals, like nurses, to solve ethical conflicts arising within the workplace. Although there are many studies with doctors on STD ethics, but only a few more targeted research on nurses. In future related research, nursing ethics researchers can pay more attention to this aspect. Simultaneously, when faced with ethical dilemmas like Alice’s, nurses should be encouraged to develop the moral sensitivity and courage to challenge ethical issues if it contributes to a high quality of care. It also points out the importance of leadership and works climate in nursing practice. Therefore, strengthening relevant training and learning has an important role in clinical practice, as the development of professional values and ethical standards has guiding implications for practice. Nurses can make their own suggestions to the relevant departments when encountering ethical difficulties to avoid falling into difficult situations. At the same time, the relevant legal departments need to seriously consider the suggestions of medical personnel and formulate relevant laws and regulations, which can not only avoid such situations, but also protect the lives of the people.

Conclusions

The ability to deal with ethical dilemmas is a necessary quality for nurses. On the one hand, nurses should respect patients’ autonomy and contribute positively to the relationship between confidentiality and the nurse-patient therapeutic relationship. On the other hand, nurses should combine with the current situation and make a targeted decision where necessary. Of course, professional code supported by related policies is necessary. Besides, the government and relevant legal departments should introduce relevant policy support to avoid clinical medical staff falling into moral difficulties.