Joshua is a good-natured and intelligent 15-year-old

Joshua is a good-natured and intelligent 15-year-old male who was diagnosed with an aggressive bone cancer and underwent a below-the-knee amputation of his left leg. Joshua’s cancer metastasized to his chest, skull, and lungs, and he was readmitted a few months later for removal of the remainder of his left leg. Joshua and your son have been friends at school for several years and you had met Joshua many times before his illness. Since then, you have been his nurse on occasion and he has talked to you about his disease. He has told you that talking about it upsets his parents and makes his friends uncomfortable so it is nice to have someone with whom he can be honest. In fact, you have always been impressed with the level of maturity and insight he demonstrates. Joshua has been readmitted, his prognosis is grim, and he is experiencing a great deal of pain. Although you have not been assigned to care for Joshua during this admission, you are aware that members of the clinical team have been uncomfortable with Joshua’s situation throughout his treatment. This is because Joshua’s parents have requested that the health care personnel limit the information they share with Joshua. This time, despite the many questions he asks, Joshua has not been told the extent of the metastases or that he will likely die within a few weeks. Members of the care team have frequently omitted information and even lied to Joshua at the insistence of his parents and with the reluctant agreement of his attending physician. Members of the care team have questioned the unit director several times about this policy; however, she continues to instruct them to respect the wishes of the parents to avoid any legal problems. Joshua’s parents also insist that he continue to receive every possible intervention and another clinical trial is being considered. One evening Joshua notices you in the hall and calls you into his room. He confronts you and tells you he knows he is not being told everything. He says he believes he is dying and, although it frightens him, he is ready to die. He has not been able to attend school for several months; his friends no longer come to see him; he knows his younger brother and sister get very little attention because of him; and he is in nearly constant pain. He is tired of pretending to be “strong and brave.” He has tried to talk to his parents but they refuse to even listen to him. He says, “I trust you to tell me exactly what’s happening and what I need to do to stop treatment, even if it is against my parents’ wishes.” As a nurse who has cared for Joshua in the past and who also knows him personally, you are faced with the practical problem of how to respond to his request to be told the truth of his condition and how to discontinue treatment. The first step in any analysis will be to gather all relevant information so that you are fully informed of the situation and its implications. For example, what are the relevant organizational policies and are there legal requirements that must be considered? Also, you may want to consider your professional code of ethics to clearly identify whether there are particular expectations of you in this situation as a member of the profession. From this point, how you solve the problem will ultimately depend on the ethical questions you ask and the ethical assumptions you consider. There is no one right solution to the problem. Let us examine some of the ethical questions that could be posed in relation to this case beginning with the ethical principles. Should Joshua’s autonomy be considered and/or honored with respect to his treatment? (respect for persons) Is Joshua being needlessly harmed by withholding information and continuing aggressive treatment? (nonmaleficence) Are Joshua’s parents and physician acting in his best interests? (beneficence) Does Joshua have a moral right to be told the truth of his condition? (veracity) To whom do I, as a nurse, owe my loyalty? (fidelity) Is Joshua being treated fairly and equitably? (justice) Is the health care team caring for Joshua being treated fairly and equitably? (justice) Similar questions can be posed from each of the theoretical perspectives. An ethic of duty will ask, “What are my duties in this situation and, if in conflict, what duty should take precedence?” An ethic of consequence will ask, “What action(s) will create the greatest benefit and cause the least harm?” An ethic of character will rely heavily on your own moral intuition and ask “What should my intentions be and what actions will serve the good?” Notice that this approach requires you to define “the good” in this particular situation as part of your analysis. Finally, an ethic of relationship will ask, “How can I best advocate for Joshua while considering other important relationships between parents, the physician, and my colleagues?” Notice that each of the questions posed is highly relevant but quite different in its focus and potential outcome. An ideal solution would address as many of these issues as possible. Unfortunately, Joshua is sitting in front of you expecting an answer now, which is why ongoing practice with ethical reflection and analysis is so important to your practice. You will not always have the luxury of time to explore your options so you need to be able to assess the ethical dimensions of a situation quickly and effectively. How would you respond

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