image via Wikimedia Commons / Jacklee

Douglas P. Olsen, PhD, RN, associate professor, College of Nursing, Michigan State University, writes about ethical issues for AJN.

On July 26, Alex Wubbels, charge nurse at the University of Utah Hospital burn unit in Salt Lake City, showed extraordinary ethical courage that will serve as an example for my students for a long time to come. She refused a police detective access to an unconscious patient so he could draw a blood sample, citing clear violation of hospital regulations, which require patient consent, a court warrant, or that the patient is under arrest. After a short, tense discussion, she was roughly handcuffed and put in a police vehicle by the detective. I recommend watching the video of the incident, although parts of it are quite disturbing. According to various analyses reported in the media, the hospital and Wubbels were legally correct and the detective’s view of her legal obligations was wrong.

All treatment, even the most minimally invasive, can be refused by a patient and therefore requires the patient’s informed consent. There are limited exceptions under which treatment can be provided without patient consent. These include:

  • When the patient lacks decision-making capacity
  • When the patient is dangerous and has a mental disorder
  • An emergency in which treatment is needed to save life or limb and the patient is unable to consent
  • A public health situation in which the intrusion to the individual (via quarantine or mandatory vaccination, for example) is outweighed by the public benefit
  • Therapeutic privilege (this is when a decision is made to not tell a patient their diagnosis)

Each exception has specific protections in place to ensure ethical decision-making. For example, when a patient lacks the capacity to make a decision, an appropriate surrogate decision-maker is identified.

In Wubbels’s case, none of the aforementioned exceptions seem to apply. Therefore, a blood draw which was not for therapeutic benefit—and which lacked consent or legal authorization—was improper.

From an ethical perspective, a nurse should not draw blood simply for forensic (not therapeutic) value without consent. In general, nurses should be careful to understand their ethical obligations whenever they are involved in procedures not being done for therapeutic value; research is one common situation.

Aside from the question of legal consent, this incident has ethical resonances. First, kudos to Wubbels, who understood her obligation to the patient, ensured that she was supported by hospital policy, and stuck to what was right despite considerable bullying—even before being physically assaulted. She did the hard thing because it was the right thing. It would have been easy to comply with the detective’s request.

Wubbels’s attorney said that the detective believed the patient’s blood could be drawn under “implied consent.” However, implied consent is an ethically dubious concept, and it certainly would not apply here. Treatment situations can be handled through explicit or substitute consent without resorting to assuming consent. One problem with implied consent is that there is no assurance that the consent is informed. Although not all nurse–patient interactions require an explicit informed consent discussion, the nurse is obligated to ensure that the patient knows what is going on and agrees to it.

This incident highlights the value of having policy in place in anticipation of such situations. (It also underscores the value of good communication, as well as the ability to de-escalate situations and to negotiate.) Wubbels’s behavior and the hospital’s policy create a forceful argument for attention to the ethical aspects of care, and for solid ethics education.

Nurses everywhere can draw inspiration from Wubbels and her confidence and use the incident as a lens for self-reflection on our own behavior in difficult circumstances—and as a model for how to behave in the future.