I wrote this essay in 1997 as a term paper for my ethics class in Nursing School. I promised to post it here a few weeks ago when the topic of patient confidentiality was discussed. By the way, my professor gave the essay a mark of 100%. Feel free to make any comments that you might have.
Love, Scully
An Ethical Dilemma Faced by Jehovah's Witness Health Care Professionals
Identify the Problem and Gather Facts
Jessica Winters (a pseudonym) has been a registered nurse for nine years. She works for a group of family physicians in private practice. Jessica is one of Jehovah's Witnesses, and has been a member of the local congregation for the past five years, along with her husband and two young children. She enjoys her job at the clinic, since it allows her to work a regular nine-to-five work week and spend after hours' time with her family and friends in her congregation. Her religious beliefs have not so far interfered with her professional judgement, nor does she make a habit of promulgating her belief system to her co-workers or the patients who visit the office -- in fact, she prefers to keep these two aspects of her life as separate as possible.
One day, a new client visits the office, someone whom Jessica recognizes as a member of a neighbouring congregation of Jehovah's Witnesses. Eric M. is an elder in the congregation, and also gives public lectures at larger conventions where several congregations are gathered at a time, but as they are not acquainted and he is seeing her out of the usual context, he does not recognize Jessica as a fellow church member, and she decides -- since the office is busy at the time -- to not identify herself as such.
Since it is part of her job to obtain the history of new clients, she conducts a brief interview with the patient, who reports that he had contracted gonorrhea, and had visited another physician for treatment initially, and had come today to have a follow-up culture done to see if he was free of the disease. As part of her patient teaching, Jessica advises Eric regarding the use of condoms with his spouse, in order to protect her from contracting the disease, and perhaps re-infecting him. Eric states that his wife is on the birth control pill, and that if he were to start using condoms, she might suspect his brief affair with a co-worker.
At this point, Jessica becomes very uneasy with the information the client has disclosed to her. His sexual behaviour outside of his marriage is grounds for him to be "disfellowshipped" [excommunicated and subsequently shunned] from his congregation. It is also the only valid grounds, according to Jehovah's Witness teaching, for the wife to procure a "scriptural divorce", one that would allow the spouse to eventually remarry. While Jessica is not formally acquainted with Eric or his family, she knows that they have children together, and that he is well liked and respected among local Witnesses. Jessica's knowledge has made her vulnerable as well. According to her belief system, if she becomes aware of "misconduct" on the part of a fellow church member, it becomes her responsibility to, first of all, encourage the individual to self-report the "wrongdoing" to the elders in his congregation. Failing that, she must report the wrongdoing herself, or risk being disfellowshipped as well, having become a "sharer in the sins of others". As a registered nurse, Jessica is bound by the Standards of Practice of her profession, which require her to maintain patient confidentiality. As well, she could put herself and the physicians for whom she works at risk of legal repercussions not covered by malpractice insurance, not to mention losing a job that she would find difficult to replace. She would likely also have to face disciplinary action by the College of Nurses, and could possibly lose her license to practice. However, as a Jehovah's Witness, Jessica believes that loyalty to God and to the Watchtower Society [the legal body representing Jehovah's Witnesses] is paramount; she feels that her own salvation will be in peril if she does not follow through and report the matter to the congregation's elders. If she does not report the matter to the elders and her knowledge is later discovered, she could be disfellowshipped, resulting in loss of contact with and being shunned by her Witness friends and relatives for a period of time, and putting her "eternal life" in peril.
This scenario constitutes an ethical dilemma for the nurse in question -- possibly even ethical distress -- since her personal beliefs and values are making demands which are diametrically opposed to those of her profession.
This dilemma is the result of an error in communication. For instance, had the nurse elected to identify herself to the patient as a fellow church member, it is not likely that he would have divulged the "incriminating" information to her; indeed, he may have requested that he be seen directly by the physician.
Also, because of their common connection to the church, Jessica may have indirectly "invited" this dilemma -- she could have stated at the outset that she had an association with the client, and had the interview handled by the other nurse in the office. Jessica could have explained the situation such that she wished to keep her personal life separate from her work, and would have had an understanding reception by her colleagues.
Either of these choices could have averted the development of the dilemma.
Clarify Values
The nurse's personal religious values in this situation demand that she take action, according to the following hierarchy:
1. confront the individual with the information and urge him to confess his "wrongdoing" to his spouse and congregation elders within a reasonable time frame, with the goal being his "spiritual restoration";
2. should the individual refuse to make a confession to the elders, Jessica's belief system demands that she report her knowledge to the elders voluntarily. [Organized to Accomplish Our Ministry, p. 142 - 145].
Her professional ethics require that she maintain patient confidentiality; this is one of the highest values in the health care professions.
Note Reactions
At this point in time, the dilemma belongs to the nurse alone. She has not yet shared her dilemma with her colleagues, or her employer, neither has she posed a "hypothetical situation" to her husband, who, upon learning of the nurse's dilemma, would be required to report her to congregation elders to advise them that a "situation" existed, nor has she consulted church literature to determine whether there might be some areas in church policy that would excuse her from breaking patient confidentiality. If she takes the opportunity to meet with one of the physicians from the clinic to explain her dilemma she would likely be advised to proceed with extreme caution, and be reminded that their respective malpractice insurance policies would not cover them for a breach of confidentiality in the event that the patient sued. The nurse would realize that not only are her livelihood and professional reputation at stake, but also her family's home, as well as those of her employers. The nurse understands that if she breaks confidentiality she will be dismissed from her job immediately and that charges will be laid, and she will be liable for fines upon conviction.
Identify Ethical Principles
Autonomy: "recognizes that a capable and competent individual is free to determine, and act in accordance with, a plan chosen by him or herself." [Keatings & Smith, p. 93] If Jessica reports the patient to church authorities, she is, in essence, taking the patient's right to autonomy away from him, since he will no longer be in control of his situation to the greatest degree possible for him.
Non-maleficence: "obliges [nurses] to act in such a way that we prevent or remove harm." [Keatings & Smith, p. 94]. The harm that would come as a result of reporting this individual is enormous, since it extends far beyond the patient, to his family, to the employer, to the nurse herself and her family.
Beneficence: "one must make a positive move to produce some good or benefit for another." [Keatings & Smith, p. 94]. The good that would be derived from the action of reporting the patient to congregation elders is in terms of her belief system, one of a higher principle -- the "cleanness of the congregation", for the individual to be returned to "an approved condition before God", and to protect her own conscience before God. The nurse must weigh these purported benefits against their inherent detriments, as described above under 'non-maleficence'.
Fidelity: "the foundation of the nurse-patient relationship." [Keatings & Smith, p. 95]. The nurse's relationship with the patient is incumbent upon trust -- the patient confided in her in good faith, with the expectation that "all communication and records pertain to his care will be treated as confidential." [A Patient's Bill of Rights, as quoted in Awake!, March 8, 1991] Reporting the patient to congregation authorities undermines that relationship, not only between the patient and herself, but between the patient and other members of the health care profession.
Clarify Legal Rules
It is clear that the legal stipulations support a decision to maintain client confidentiality. The nurse would be well aware that under the Regulated Health Professions Act, 1991, (RHPA, 1991) that she is obliged to
preserve secrecy with respect to all information that comes to his or her knowledge in the course of his or her duties and shall not communicate any information to any other person -- Section 36 (1).In reviewing the RHPA, 1991, the nurse realizes that
Every person who contravenes subsection 36(1) is guilty of an offence and on conviction is liable to a fine of not more than $25,000 -- Section 40(4).Jehovah's Witness are very aware, through their regular religious publications, of their rights as patients. Awake! readers are advised that:
The patient has the right to:However, church policies are deemed to be "the superior demands of divine law" [The Watchtower, September 1, 1987, p. 15], and it presumes that it would be necessary for the nurse to determine exactly what the "divine law" demands in this situation, which is addressed by a single Watchtower article. I have compiled a list of quotations and scripture, to sort out ideas in a logical manner.
[. . . ]
5. Every consideration of privacy concerning his own medical-care program.
6. Expect that all communications and records pertaining to his care will be treated as confidential. [March 8, 1991, p. 7]
[E]ach Christian [Jehovah's Witness], if ever faced with a situation of this nature, must be prepared to weigh all the factors involved and reach a decision that takes into consideration Bible principles as well as legal implications and that will leave him with a clear conscience before Jehovah. [p. 12] (emphasis added)The nurse might decide that since she is not an eyewitness, her testimony will not be valid.To establish a matter conclusively, the testimony of at least two eyewitnesses is needed. [p. 12] (emphasis added)
There may be times when a [Jehovah's Witness] is obligated to bring a matter to the attention of the elders. True, it is illegal in many countries to disclose to unauthorized ones what is found in private records. But if a [Jehovah's Witness] feels, after prayerful consideration, that he is facing a situation where the law of God required him to report what he knew despite the demands of lesser authorities, then that is a responsibility he accepts before Jehovah. There are times when a [Jehovah's Witness] "must obey God as ruler rather than men." -- Acts 5:29. [p. 13]The nurse may come to the conclusion that her "personal convictions", based on her research into church literature and Scripture, are such that she cannot, in good conscience, disclose confidential client information to church authorities.There may be occasions when a faithful servant of God is motivated by his personal convictions, based on his knowledge of God's Word, to strain or even breach the requirements of confidentiality because of the superior demands of divine law. [p. 15] (emphasis added)
Elders may be approached by individuals who either confess their own sins or report what they know regarding the wrongdoing of others. [Organized to Accomplish Our Ministry, p. 145]The nurse may decide, on the basis of this information, that because she is not an "eyewitness" to the "wrongdoing", and would be 'just a person repeating what they have heard', that she is justified in not reporting this individual to congregation authorities, and maintaining client confidentiality.If a person has definite knowledge of wrongdoing that could contaminate the congregation, he is obliged to report the matter in order to keep the congregation clean. [Pay Attention to Yourselves and to All the Flock, p. 97]
There must be two or three eyewitnesses, not just persons repeating what they have heard. [Pay Attention..., p. 109] (emphasis added).
In a consultation with a Jehovah's Witness elder who has a 25-year association with the church, the above-quoted article was discussed and I asked what the church requirements would be in this situation. He stated without hesitation that the nurse should report the matter to the congregation elders if the patient is not willing to self-report. I asked him what would be provided by the congregation or its leadership to the nurse for adhering to church policy, in the event that the patient sued her for breach of confidentiality. My source stated that the nurse, having contravened "Caesar's law", would have to accept whatever were the consequences of her actions, and could not expect her congregation or the Watchtower Society to support her in this instance, either in a financial way or with legal assistance. I also asked him whether church policy had precedence over Scripture, and he assured me that the Bible was considered to be the final authority.
The one walking about as a slanderer is uncovering confidential talk, but the one faithful in spirit is covering over a matter. -- Proverbs 11:13 [NWT]Explore Options and AlternativesDo not reveal the confidential talk of another. -- Proverbs 25:9, 10 [NWT]
a) Do Nothing
In posing this dilemma to several acquaintances, the consensus was that even if the nurse decided to ignore church policy, there would still be the potential for repercussions against her:
if the nurse and the [patient] decide to ignore the situation for now, but later he has pangs of conscience, reports his misconduct to the elders, and then finds out that the nurse was a J[ehovah's] W[itness]. He then reports her to her elders, who call her on the carpet for failing to report a wrongdoing. Or suppose the elder finds out who the nurse is, fears that she may try to report him, and turns himself in before she has the chance so as to head her off, then reports her for failing to report him in order to take some heat off himself. She is then put in a position of having to defend herself, and would likely be at least privately reproved. Of course, should she defend herself with the scriptural arguments that you advanced, she would be seen as failing to accept Godly counsel and almost certainly be [disfellowshipped]. No matter what, she loses big time. [e-mail communication]Doing nothing will satisfy the duty that she owes to the patient in her role as a nurse, since it is an inherent part of the nurse-patient relationship that she maintain confidentiality. The patient did not approach the nurse to 'confess sins', and the nurse does not assume this role in the practice of her profession. It has been her practice to keep her professional and religious activities separate to the greatest extent possible, and in this situation, doing nothing would be a continuation of this practice. The patient's autonomy is respected, and harm does not come to the patient. The nurse's fidelity and integrity with respect to her profession remains intact, as well.
While resulting in her following legal principles, the nurse will likely still have pangs of conscience from not having researched her church policies thoroughly, and as shown above, there will always be the possibility of repercussions within the church hierarchy. The "good consequences" derived from doing nothing are that the patient's autonomy is respected, and that no harm comes to him. The nurse's fidelity and integrity with respect to her profession remains intact.
b) Follow Legal Principles
Legal rules demand that the nurse not disclose confidential information in this situation. Her conscious decision to follow the rules, in spite of her religious beliefs will place her at risk for disciplinary action by church officials if she is discovered to have this knowledge. However, the patient's autonomy and right to confidentiality is preserved, and the nurse's professional fidelity and integrity remain intact.
This could prove to be a detrimental decision for the nurse, since her "spiritual-ethical-moral view of self", "self-consistency", and "self-ideal/self-expectancy" [Roy & Andrews, 1991, p. 312] will have been compromised. She may experience guilt, anxiety, and feel that she has committed a sin against her God and her church. Insofar as the client is concerned with respect to church policy, the nurse may resent the client for putting her "on the spot", and this may compromise future care that she gives to him or other Jehovah's Witness patients.
c) Follow Church Policy
The nurse, in reviewing church policies and Scriptures that are germane to the case, would realize that there are steps she must take before she reports this individual to church authorities. First of all, she would have to approach the patient and identify herself to him as a fellow church member. She would then have to explain to him the difficult position in which she finds herself, and determine whether the patient has self-disclosed to his congregation elders already, which would allow her to maintain the information as confidential and satisfy church policy. In the case where the client has not yet self-reported to church authorities, he has three options:
1. choose to self-report, in which case the nurse would not have to proceed further;
2. decline to self-report and provide written consent to her disclosing the information to church authorities, which would absolve her of legal repercussions under the RHPA, 1991 [sect 36(1)(f)] -- [extremely remote possibility];
3. decline to self-report and refuse to consent to disclosure, in which case the nurse would have to determine whether she wants to take the next step and divulge confidential information to church authorities.
In speaking with the patient and describing her ethical dilemma to him, the nurse may feel that she is respecting his autonomy, and making an attempt to maintain her professional fidelity and integrity to him. She is also satisfying church policy, without yet compromising her professional ethics. In fact, church literature suggests that this course of action would be "a loving approach" since the patient might "welcome the opportunity to clarify matters" [Watchtower, September 1, 1987, p.14]. The nurse's efforts to resolve this issue privately with the client would likely satisfy her self-ideal, in that she would feel that she did everything in her power to avoid having to disclose confidential information unlawfully.
In completing further research regarding church policy, the nurse may determine that she has a greater obligation to abide by her oath to preserve client confidentiality, since the Scriptures definitely speak to the issue of maintaining confidence and the sacredness of taking an oath, and with church literature impressing the idea that one's "personal conviction, based on his knowledge of God's Word" that it is better for her to retain the patient's confidence and suffer the potential consequences of not reporting the patient to church authorities. Should she report the client without his consent, she is liable for the offense. She will be dismissed from her job, and charged. She will have to pay the fine determined by the court, and will also be liable in the event of a suit by the client. The possibility also exists that the client could sue individual members of any judicial committee assembled, since there would be a passing on of confidential information among them as a result of the nurse's report.
Even though the nurse may feel that this approach satisfies legal requirements and church policy, the nurse, in approaching the patient with her dilemma is undermining her role with respect to this patient, even though his autonomy, i.e., his right to retain control of his situation, is respected. "The patient has the right to . . . expect that all communications and records pertaining to his care will be treated as confidential" [Awake!, March 8, 1991, p. 7], therefore, approaching the patient in this manner threatens the trust [i.e., fidelity] between the nurse and patient. As well, the principle of fairness comes in to play, since the patient may feel that he is not being treated with 'unconditional positive regard' that is due him by the health care professional, [Lefton & Valvatne, pp. 408-412].
Decide the Course of Action and Develop an Action Plan
The course of action that seems to be the most reasonable consists of the following steps:
1. the nurse should speak to the employer to let her dilemma be known, so that she can have the assistance necessary to make an informed and ethical decision and to assist in developing policy to circumvent future instances of this type of ethical dilemma;
2. research the church literature to clarify her own values regarding the situation; and
3. speak to the client and identify herself as a fellow church member; advise him that she is not going to divulge this information to church authorities because her research has brought her to the conclusion that her obligation to maintain confidentiality was supported by Scripture, even though it contravenes church policy, and because of the heavy penalties that would result from disclosing confidential information to unauthorized persons.
The nurse may also decide to take the further step to:
4. advise her congregation elders that she is faced with an ethical dilemma that involves another church member in a different congregation; that this dilemma involves confidential information obtained in the course of her professional practice; and that she has "prayerfully" researched church literature and has come to the conclusion that she can not divulge any confidential information, and that she is prepared to accept the consequences of the decision imposed by the church authorities. She may explain the heavy penalties that she and her employer will face, and that any judicial committee assembled with regard to her client may also face legal action by the client.
Evaluate the Plan
In determining the effectiveness of the plan of action, the nurse will note her client's response to her efforts to maintain confidentiality, which hopefully will be positive. She will also work along with her employer to develop a policy that will circumvent similar types of ethical conflicts in the future. The nurse will also feel that she has dealt with the situation to the best of her ability without compromising legal considerations or church policy, given the information available to her, and her understanding of the law as it applies to her nursing practice, and of church policy and Scripture. There will likely be pressure put upon her to divulge this information by church authorities, perhaps to the point of being publicly reproved for not co-operating with the elders, however, the nurse is prepared to accept the consequences of this decision.
Bibliography & References
Bullock, G.L., (1985). In Medical Economics, August 19, 1985 [Referenced by: Franz, R.V. (1991). In Search of Christian Freedom. Atlanta:Commentary Press.] (Source of Scenario).
"Scully" (1997). Evolution of Nursing [NSG4043], Class Notes [unpublished].
Keatings, M. & Smith, O. (1995). Ethical & Legal Issues in Canadian Nursing. Toronto: Saunders.
Lefton, L.A. & Valvatne, L. (1992). Understanding Psychology. Fourth Edition. Massachusetts: Allyn and Bacon.
Potter, P.A. & Perry, A.G. (1993). Chapter 13: Ethics. In Fundamentals of Nursing, St. Louis: Mosby's Year-Book.
Queen's Printer for Ontario. (1994). Regulated Health Professions Act, 1991. Toronto: Publications Ontario.
Roy, C. & Andrews, H. (1991). The Roy Adaptation Model: The Definitive Statement. Third Edition. Norwalk, Connecticut:Appleton & Lange.
College of Nurses of Ontario. (1995). Guidelines for Professional Behaviour, Toronto:CNO.
Publications of the Watchtower Bible and Tract Society:
(1991). Pay Attention to Yourselves and to All the Flock.
(1990). "A Patient's Bill of Rights", Awake!, Vol. 72, No. 5, p. 7.
(1987). "A Time to Speak" - When?, The Watchtower, Vol. 108, No. 17, pp. 12 - 15.
(1984). New World Translation of the Holy Scriptures, [NWT].
(1983). Organized to Accomplish Our Ministry.
Consultations:
Mr. G. S., a Jehovah's Witness elder, and 25-year member of the religion.
Mr. A. F., a member of Jehovah's Witnesses for 40 years.
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