NUR 3320 Module 3 Bedside Ethics Paper: The Four Principles and the ANA Code in a Refusal of Care Example

She Said No: Autonomy, Beneficence and a Feeding Tube After Stroke

Student Name

B.S.N., Accelerated Second Degree, Thomas Edison State University

NUR-3320: Nursing Science Foundations: Theory, Ethics, and Practice

Mentor Name

Month Day, Year

She Said No: Autonomy, Beneficence and a Feeding Tube After Stroke

Introduction

Ethics in my first semester seemed like a matter of rules. Then I met a patient whose clear refusal of treatment put her son, her physician and the nursing staff in conflict. This paper analyzes the case using a principle-based framework and the profession's code and recommends what a nurse should do.

The Case

Mrs. Romano is invented for this paper. She is 81 and widowed, and she lived alone until a stroke two weeks ago left her with weakness on the right side and difficulty swallowing. A swallow study showed she aspirates thin liquids and some solids. The team recommended a feeding tube while she undergoes rehabilitation, which might restore safe swallowing over weeks or months. Mrs. Romano speaks slowly but clearly. She says she has lived a full life, watched her husband suffer on machines and refuses the tube. Her son, who lives close by and holds her health care power of attorney, insists that she is depressed and not herself, and he asks the team to place the tube anyway. The nurses caring for her are divided.

The Four Principles

Beauchamp and Childress (2019) proposed four principles as a framework for biomedical ethics. Respect for autonomy asks us to honor decisions made by people who are able to make them, and to support them in deciding. Nonmaleficence requires avoiding harm. Beneficence requires acting to benefit others and balancing benefits against risks and costs. Justice requires fair distribution of benefits, risks and costs. The principles are prima facie: each is binding unless it conflicts with another, in which case the conflict must be resolved by judgment.

Gillon (1994) defended the four principles as a common moral language across cultures and added that one must also attend to their scope: to whom do we owe each duty, and how far does it extend? For example, respect for autonomy is owed to those capable of autonomous decisions, and the scope of beneficence is shaped by professional roles.

Applying the Principles

Respect for autonomy weighs heavily. If Mrs. Romano has decision-making capacity, her refusal must be respected even if others disagree. The key question is capacity: does she understand the facts, recognize that they apply to her, compare the options and state a choice? Her son's concern about depression is legitimate; depression after stroke is common and can impair decision making. But disagreement with a choice is not evidence of incapacity.

Beneficence favors the tube if there is a fair prospect that she will eat safely again and a life she would value. Nonmaleficence cuts both ways: a tube carries risks of infection and discomfort, while refusing it risks malnutrition and aspiration. Justice matters less here, though it means her care must be just as good, including palliative support, whatever she decides.

The ANA Code

The Code of Ethics for Nurses sets out nine provisions (American Nurses Association, 2015). Provision 1 sets compassion and respect for each person's dignity and worth at the heart of practice, which includes the right to make one's own decisions. Provision 2 makes the patient, whether a person, family, group or community, the nurse's first commitment. Provision 3 calls on the nurse to speak up for the patient's rights and to protect her health and safety. Provision 5 extends the nurse's duties inward, to the nurse's own health and integrity.

Under Provision 2, Mrs. Romano comes first, not her son, though the family deserves compassion and inclusion. Under Provision 3, the nurse advocates for her right to have her decision heard and properly assessed.

Cultural and Religious Considerations

Mrs. Romano's family is Catholic, and her son mentioned that his mother had always said life is a gift from God. Some patients and families understand refusing nutrition as forbidden by their faith, while others see burdensome treatment as optional. The nurse should not assume either view. Asking Mrs. Romano directly how her faith shapes her decision, and offering a visit from a chaplain of her tradition, respects her values and may help the son see that her choice is consistent with them.

A Recommended Nursing Response

The nurse should take several steps. First, advocate for a formal capacity assessment, possibly with input from psychiatry to evaluate and treat depression. Second, spend time with Mrs. Romano exploring her values and her understanding of the tube's purpose and likely course, including that it may be temporary. Third, support a family meeting with the physician, social worker and, if desired, a chaplain, where her son can express his fears and she can explain her wishes. Fourth, if she has capacity and maintains her refusal, ensure she receives excellent care focused on comfort, safe feeding as tolerated and support. Fifth, involve the ethics consultation service if conflict persists.

The Son's Role

In most states a health care agent's authority begins only when the patient can no longer decide. If Mrs. Romano has capacity, her own decision governs. The son's distress deserves attention, and nurses can help him understand that honoring her wishes is a form of care.

Limits

Capacity assessment is a medical and sometimes legal judgment, not a nursing decision alone. Laws vary by state. Mrs. Romano and her family are invented.

Conclusion

Beauchamp and Childress's principles show that both the son's request and the patient's refusal draw on real moral values, and Gillon's attention to scope reminds us that autonomy is owed to those with capacity. Under the ANA Code, the nurse's first loyalty belongs to Mrs. Romano herself. The ethical path is to assess capacity carefully, explore and treat depression, communicate openly with the family and, if she has capacity, honor her decision with excellent care.

References

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association.

Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Gillon, R. (1994). Medical ethics: Four principles plus attention to scope. BMJ, 309(6948), 184-188. https://doi.org/10.1136/bmj.309.6948.184