In the documentary The Invisible Patients, Jessica, a nurse practitioner for home-limited patients, is faced with several ethical dilemmas. For example, Jessica provides care for an elderly couple named Wink and Patty Sherrill. Both Patty and Wink are prescribed narcotics to manage their arthritis pain. During a routine urine drug screen, it is discovered that Patty does not have any trace of her pain medication in her system, yet she is still having her narcotic prescription refilled regularly. This obviously raises concerns for medication diversion. Patty is presumably giving her narcotics to her husband or selling her narcotics, which is a clear violation of her pain contract. She is banned from her primary care MD’s practice, which causes her great difficulty in finding another healthcare provider. Jessica feels that it is her responsibility to provide care for this couple.
This scenario raises the ethical dilemma of beneficence versus nonmaleficence. The principle of beneficence is “the duty to do good and prevent or remove harm” (Hamric, Hanson, Tracy, O’Grady, 2014, p. 337). Prescribing narcotics to those experiencing chronic pain and disability is a necessary and beneficent act of healthcare providers. The principle of nonmaleficence is “the duty not to inflict harm or evil” (Hamric et al., 2014, p.337). Prescribing narcotics to a patient who is suspected of narcotics diversion has the potential to cause harm to the person who is taking the narcotics illicitly. Jessica must now decide which principle to follow and which principle to potentially break. Jessica decides that even though Patty is abusing her prescription, she does in fact still need her narcotics and continues to prescribe the pain medicine.
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In this scenario, I would not continue to prescribe Patty narcotics. Since she is not taking her pain medications but still seeking refills, she is abusing her prescription and the trust placed in her. If she is diverting her narcotics to her husband and/or selling them on the street, this places Wink and/or the narcotic abuser at risk for health complications such as respiratory depression, constipation, drug dependence, increased tolerance, and narcotic withdrawal in the future. I believe Wink has a legitimate need for pain medications, but he should be honest and open with Jessica about the need to increase his pain medications or try different modalities if his pain is not properly controlled. Regardless of motive, illegally diverting narcotics is a breach in contract and should not be overlooked.
If I were presented with this scenario, I would have talked with Patty and Wink about Patty’s narcotic diversion and sought an alternative solution to continuing to prescribe narcotics. If Patty were in fact giving her narcotics to her husband to help control his pain, I would adjust Wink’s medications and pain management strategy. If they were selling their excess narcotics on the street to help pay for their bills or health insurance (which Patty frequently mentioned), I would consult a social worker to help Patty and Wink manage their finances and review insurance options. Narcotic abuse is an epidemic in America, and nurse practitioners must use wisdom when prescribing narcotics (CDC, 2017). Pain management is certainly a responsibility of the nurse practitioner and should always be considered when providing care.
Personal Beliefs and Values: Costs and Benefits
I believe that individuals should be held accountable for their actions. Though it is sad to think that some individuals feel they must break the law to “make ends meet”, that does not make it right. I tend to see things as black and white, and I realize that this is a barrier when facing ethical dilemmas. Ethics and medicine have many grey areas, and I must be cautious to not let my personal views affect how I care for my patients. One may argue that Patty felt she had no other choice, and it was a necessary means for Patty and Wink for them to survive on such a limited income. Though I disagree with this argument, I must still be willing to consider the opposing view before making my final decision. By pausing and considering the opposing viewpoint with an open mind, I can begin to overcome my personal bias when faced with an ethical dilemma.
A potential cost to my barrier of being a dichotomist thinker is that I may fail to see an alternative solution. There are often more than just two solutions to a problem, and I need to actively seek creative, alternate solutions before coming to a decision. A potential benefit to my beliefs is that I do not tend to ruminate over past decisions. Working in healthcare is often emotionally taxing and can lead to burnout if you let it consume your thoughts.
According to our text, disruptive innovators are individuals who provide a cost effective, convenient service to a customer who is less demanding than the typical customer (Hamric et al., 2014). This creates competition between the disruptive innovator and the larger corporations and often drives down prices of the larger corporation. Nurse practitioners, such as Jessica, can provide excellent care to patients at a cheaper price and deliver this care conveniently at home. Providing care to homebound patients such as those in The Invisible Patients is an excellent example of a service that is competitively priced and convenient for the less demanding patient population.
ANA Code of Ethics
The ANA Code of Ethics is a grouping of morals and values that nurses are expected to adhere to during their career (ANA, 2015). Nurses must use this code when faced with difficult ethical dilemmas. An example of a barrier regarding the ANA Code of Ethics could be found with Provision 3: “The nurse promotes, advocates for, and protects the rights, health, and safety of the patient” (ANA, 2015, p.8). For example, if a nurse is caring for a patient that confesses to elder abuse, the nurse must now report that patient to the police and fail to protect the patient’s right to confidentiality. Most nurses would agree that this is the correct action to take, but some may mistakenly believe that Provision 3 prohibits reporting the incident to the police. This is a barrier of the ANA Code of Ethics as well as a barrier due to simply a lack of understanding. The Code of Ethics is a great tool for nurses but also has the potential to be a barrier in healthcare if misunderstood.