Abstract

The duties of the nurse and the nurse–patient relationship

Although the specifics of the duties of a nurse may vary among nursing communities, the ultimate aim universally is to improve or maintain a patient's wellbeing. The achievement of this aim encompasses the provision of care to patients with their best interests driving decisions, and using the specialist skills and knowledge that a nurse has.

In order to provide effective healthcare, the nurse–patient relationship needs to be established and, most importantly, the patient must establish trust in the nurse. The nurse invites trust through her professional position. This trust gives the nurse responsibility as the patient has confidence in her motives and decision making. The patient, trusts and expects the nurse to be truthful.

In this scenario, the nurse has not been truthful to the patient. However, she has not actively lied. Her words imply she is offering active treatment, but she does not actively state this, effectively making it deception without lying.

Telling the patient a straight lie would be morally wrong¹ and would directly conflict with the expectation and trust of the patient in the nurse; however, not telling the truth is less clear‐cut. A distinction must be made between not lying and not telling the truth. The nurse has a duty not to lie, but not necessarily a duty to tell the whole truth, as this is not always possible—for example, the nurse is unlikely to tell the patients of all of the unwanted and unpleasant symptoms and pain they may suffer due to their AIDS. In such a case, the nurse has intentionally deceived the patient as the nurse feels the information is not necessary for the patient to know. Is this deception without lying any different to lying when the end result is the same, or is it a distinction without a difference?

Despite the deceit, the nurse is fulfilling the duty to do what she feels is in the patient's best interest. The nurse has judged her duties to be conflicting and that the duty to make the patient feel better takes precedence over the duty to be truthful. In doing this, the nurse may be taking advantage of the patient's trust in her care and that actively deceiving the patient is morally wrong, independent of what is in the patient's best interest and the fact that the nurse has no personal gain motivating her.

Beneficence versus truthfulness

Raanan Gillon² argues that, in relation to deception, the principles of non‐maleficence and beneficence can override the responsibility of not deceiving. The nurse accomplishes these principles, as her motive in her deception was to make the patient feel better, and she acted in entirely good will. Assuming the nurse's deception is not found out, there was also no apparent harm caused to the patient (non‐maleficence). Therefore, in this case, according to Gillon's reasoning, the nurse's deception is defensible. However, should the patient find out about the deception, Gillon's argument falls, since, despite the beneficent intention, the patient may be psychologically harmed and the nurse–patient relationship damaged. However, the nurse's alternative here is to offer the patients nothing that may also be harmful to them. Perhaps it is still defensible, since the risk of harm to the patient as a result of finding out the deception and the extent of this harm may be less than harm caused by providing no treatment to a vulnerable and desperate patient.

The placebo effect and nursing interventions

The aim of giving a placebo is to induce the placebo effect. Until recently, this has been associated with psychological effects; however, recent studies have linked the psychological and physiological effects of placebos and a number of neurobiological mechanisms have been suggested.³ Lichtenberg⁴ argues that placebo is a deception only for those who would reduce treatment to a purely biomedical pursuit. This is relevant in this case as it is the act of taking the medicine (which has no active ingredient to help the symptoms of AIDS) rather than an effect of the medicine itself, which results in an increase in feelings of well‐being. This may be due to processes involving expectation and conditioning which leads to a neurophysiological response.⁵ Nurses intervene in various ways to affect the health of the patient. This can include simply spending time with them through counselling or, as in this case, by giving placebo drugs. These are psychosocial rather than biomedical measures, and it can be argued that the patient makes a general assumption of a patient that because the intervention is in the form of a pill and that it is a biomedical intervention.

It is universally agreed that a nurse should not intentionally cause harm to a patient (non‐maleficence), although harm may sometimes be caused as a byproduct of a beneficent act—eg, pain caused when giving a therapeutic injection. The placebo must be of a substance which can benefit the patient, with minimal or no harm done. If there is harm done to the patient, without them having consented to this treatment, then the deception is indefensible. However, in this case, the tablet itself is harmless and will not cause the patient any physical harm. It can be argued that, because the result of the intervention is positive, the nurse was acting with good intentions (beneficence) and that since no harm to the patient, the act of deception is defensible.

Potential long‐term consequences and the community

Although in the short term the placebo evidently benefits the patient by making him or her feel better and will not inflict physical harm, there is the possibility of harm in the long term should the nurse's deception be found out. There would be several implications of the patient finding out the deception, which is improbable but possible. Firstly, the placebo's effectiveness would diminish the possibility of a decrease in well‐being. The patients are likely to be upset and possibly angry with the nurse for deceiving them. The patients' feeling better would likely no longer be the case, and they could be psychologically harmed. This would be directly through the act of having being deceived and, adding to this, the deceit may have been going on for months or even years. Crucially, the trust between the nurse and patient is broken down.⁶ This has further implications. As discussed previously, trust is essential for an effective nurse–patient relationship and, once broken, is extremely difficult (sometimes not even possible) to heal. It may affect not only this particular nurse but also the nursing and healthcare community as a whole. The patients may not accept further treatment offered, and thus subject themselves to further health problems. What starts as a potential psychological harm can become a physical harm.

The other issue is the wider community. This is the major long‐term problem with this deception without lying. The nurse works in and among the whole village, which is a close‐knit community and in a situation such as this, where most of her patients have AIDS, she may well be treating family members and others very close to the patient. The discovery of a deception such as this could have severe implications on the health of the whole local community as they could lose faith in the healthcare available as a whole.

On taking a closer look at the community that this scenario is based on, it is clear that most people live in extreme poverty. They do not have access to adequate healthcare, indeed this community nurse may be their only access. The fundamental problems are lack of transport meaning patients cannot get to healthcare facilities—or lack of funding to pay for treatment. These problems show how, although treatment is available for patients with AIDS elsewhere, it is not available to most of this particular population and therefore active AIDS treatment is effectively not available here. This situation gives the nurse several alternatives in terms of what she offers her patients. Being truthful and offering the patients no treatment will not benefit their physical or mental health, and they may feel psychologically worse. By giving the placebo, the nurse is preventing this potential psychological harm, and making them feel better, thereby raising their spirits and not taking away their hope. Of course, this second option requires deceit on the nurse's behalf, deceit as a byproduct of a well‐meaning act. It is noteworthy that, whichever option the nurse chooses to take, the patient will remain terminally ill. Placebo or no placebo will have no effect on the natural course of the disease; the placebo purely provides a psychological “pick up” and, as discussed previously, assuming the nurse's deceit is not found out by the patient or local community, no harm is caused.

It is also noteworthy that were the nurse to explain to the patient that she was offering a placebo, the placebo effect would not work. Any patient is likely to understand that taking a dummy pill will have no effect on them, and thus they would gain no therapeutic effect. This therefore is not a viable option for the nurse.

An assumption that the nurse is making when giving out the placebos is that there is absolutely no option of the patient getting hold of active treatment. As improbable as it is, for a patient living in poverty in a remote area to have this access, it is not necessarily the right of the nurse to make this judgement. Potential harm could come of this assumption as, should the patients believe they are receiving active treatment, they make not actively seek it if they were in the unlikely position to have the means to do so.

The value of the psychological placebo effect is subjective and is different in every patient's case. What people value varies enormously, and, in such a time at the end stages of one's life, these values can be deemed more important than ever. One of the values that the placebo effect has on most people is quality of life, which again is subjective. A better quality of life can potentially be achieved by giving the patient hope for better health. The patients are not under the deception that the pills will cure their AIDS, but perhaps have hope that their condition will improve, thus having an effect on their quality of life before it deteriorates significantly. This may provide a longer spell of well‐being than they would have without the drug. However, through having a greater sense of well‐being, the patients can be given false hope as a consequence of the deception. Although they may feel better, they may be being denied time to prepare for death. Perhaps they would choose to make plans or to do things before they get too sick to be independent. Perhaps if the nurse were honest with the patients and effective counselling were offered, the patients would be able to come to terms with their death. Through this deceit, the nurse may be taking away this chance from them. The nurse knows the patient on a professional rather than personal level, and yet has made judgements, not only about the patient's physical, but also about their psychological and spiritual health. Is it the nurse's place to make such assumptions when she only has the perceived patient's best interest?

Autonomy and paternalism

When patients are being deceived in this way, they are not taking the drug which they believe to be taking. How can patients consent to taking something if they are unaware of what it is? They have been denied the information that enables them to make a rational decision. It is questionable who is in the best position to be deciding what is in the best interest of the patient. In terms of health, the nurse is in a better position to judge on account of her experience and knowledge; however, without fully informing the patient about the medication, the nurse is not obtaining informed consent, thus the patients are unable to make an informed decision about their treatment. It is noteworthy that the patients whom the nurse is treating are critically ill, and are likely to be feeling quite scared and vulnerable, and are likely to accept any treatment that the nurse is offering.

One of the main problems with the deceit, apart from the breaking down of trust, is the issue of patient autonomy. If patients are not fully informed about their health by the nurse, and if they are not aware of what options are open to them, how can they exercise their autonomy? Effectively, the nurse is denying them this right. Literally, autonomy means to rule one's self, and generally encompasses the patients' ability to think and reason for themselves and to make decisions and act on those, on the basis of those thoughts and reasoning. By not explaining the situation fully to the patient and through the act of deception, the nurse is not showing respect for the patient's autonomy, and the patient may be disadvantaged as a result. Although the patient has the capacity to think and make decisions, without the nurse providing the information the patient is unable to reason, and subsequently is not in a position to make an autonomous decision. The nurse is making assumptions about what decisions the patient might choose to make.

However, there is a chance that patients may prefer to be deceived and not want to know the truth that there is no help available for them. Obviously, by the deceit they are unable to make this decision for themselves, which is a breach of their autonomy. However, should patients be told things they would rather not know which may affect negatively on their psychological health purely for the sake of their autonomy?

According to Downie and Calman,⁷ paternalism involves choices being made incorporating the inhibition of freedom, motivated by doing what is best for the patient. According to this description, through this deception the nurse is taking on a paternalistic role. She is not respecting the patient's autonomy and is making decisions on the patient's behalf, without the informed consent to do so. Is it right that the nurse should take the decision to take on this role? She is effectively inhibiting the patient's autonomy and making a decision about the patient's treatment based purely on her own knowledge, rather than on the patient's feelings and/or beliefs.

Conclusions

In conclusion, the actions of the nurse, although understandable and defensible, are probably unethical. She fulfilled her overall duty to improve the well‐being of the patient, but at what cost? Although each individual patient is unlikely to come to harm, the long‐term and widespread harm that could potentially result cannot be ignored. If the trust is broken down between the community as a whole and the healthcare system, people in already desperate situations are left only more desperate. What little help was previously available to them becomes no help at all. This demonstrates just how crucial trust is. It also demonstrates the detrimental effects that lack of truthfulness can instigate, short term and long term, local and more widespread.

However, it is important to remember that this cost or harm to the community is a potential one. The nurse was experienced and was probably aware of the risk that she was taking and that the risk of it happening was likely to be very small. Taking aside this risk, does the end result justify the means? Is the deception itself justifiable? Positively, she does succeed in making patients feel better (her ultimate aim in her job), she eases their suffering at a very difficult and painful time. The value of this is immeasurable, as it is not possible to gauge what the exact effects of being entirely honest would have been. However, based on the nurse's experience, she deems the placebo to have a sufficiently significant effect on the patient's well‐being to justify her deception. It is important that the nurse gains nothing from it and that her intentions are undeniably entirely honourable.

Although the nurse feels that she is doing what is in her patient's best interests, is she the right person to be making such judgements? She does not know the patients on a personal level, and therefore does not know their beliefs or opinions. She is making assumptions regarding what the patient supposedly wants. She is also potentially denying them active treatment (however as discussed, this is unlikely), and also the time to make plans for their deaths or do things they wish to while they remain independent and mobile.

By deceiving her patients, the nurse is taking on a paternalistic role and is inhibiting the patient's ability to exercise their autonomy. The patients are not informed about what they are taking and therefore are not consenting to the particular treatment.

In summary, it is ethically wrong for the nurse to intentionally deceive her patients, independent of motivation. The fact that the nurse used deception without lying as opposed to a straight line is of little relevance since the end result is the same. It is indeed more understandable to deceive when no active harm comes to the patient and when the nurse is acting benevolently; however, the act of taking away the patient's autonomy and risking the health of the community in the long term is not. By judging and deceiving the patient, an immoral assumption about the patient's wishes is being made by the nurse, and fundamentally this is not ethically right.

Acknowledgements

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