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Volume 9
Number 4

In this Issue

Introduction

Special Issue: Ethics

Medical Repatriation: Physicians’ and Nurses’ Responses to a Dilemma

Respecting Vulnerability: Informed Consent in Persons with Alzheimer’s Disease

Conducting Research with the Elderly: Ethical Concerns For a Vulnerable Population

Ethical Issues in Conducting Research with Persons with Dementia

Other Original Research

Parent Involvement in Functional Assessment of Problem Behaviors Related to ADHD as a Basis for Intervention Selection

Surviving Postpartum Depression and Choosing to be a Mother

“Sibling Closeness,” a Concept Explication Using the Hybrid Model, in Siblings Experiencing a Major Burn Trauma

Do Peer-Led Parent Groups Make Young Mothers Better Parents?

The Relationship between Baseline Self-Efficacy and Breastfeeding Duration

Medical Repatriation: Physicians’ and Nurses’ Responses to a Dilemma

(Download PDF)

Jill E. Winland-Brown, EdD, MSN, FNP-BC
Professor and Family Nurse Practitioner
Florida Atlantic University
Port St. Lucie, FL 34986
winbrown@fau.edu
(772) 538-3124

Adam L. Dobrin, PhD
School of Criminology and Criminal Justice
Florida Atlantic University
Boca Raton, FL 33431
adobrin@fau.edu

Medical Repatriation: Physicians’ and Nurses’ Responses to a Dilemma

Medical Repatriation is an institutional dilemma that affects physicians and nurses. This study analyzes the responses of physicians and nurses to a hypothetical case study involving a young man deported back to Honduras for lack of medical resources. Descriptive statistics and tests of significance were done to examine the responses to the dilemma. There was no significant difference between the responses of physicians or nurses whether the patient should be medically repatriated. The only variable that was significant when considering deportation was ethnicity. The majority of the respondents had received no prior ethics training in the past while many of them have experienced prior moral distress related to an outcome of an ethical decision. When asked about solutions, respondents had several suggestions. Recommendations include involving the Hospital Ethics Committee, searching for additional resources to allow this patient to remain in the United States to receive rehabilitation services, and providing ethics training for physicians and nurses to enable them to resolve ethical dilemmas using principled thinking and to hopefully decrease moral distress.

Keywords: medical repatriation, ethical dilemma, moral distress

Medical Repatriation: Physicians’ and Nurses’ Responses to a Dilemma

Jose Rivera, age 25, is an illegal Honduran immigrant. He was admitted to the hospital after the landscaping truck he was riding in overturned on the highway. After multiple surgeries including bilateral above-the-knee amputations and over a million dollars in hospital bills, Jose is ready to go to a rehabilitation facility. There is no facility that will accept Mr. Rivera because of his inability to pay and lack of health insurance. The hospital is contemplating medical repatriation where they would pay $30,000 for an air ambulance to forcibly return him to a hospital that has agreed to accept him in Honduras. The hospital can no longer give free care for an extended stay. How would you respond?

This hypothetical case study suggests the ethical problem that physicians and nurses face when dealing with an institutional dilemma. Medical repatriation occurs when a noncitizen is sent back to his or her home country because of some medical ailment. Historically, during the Ellis Island era, this was due to some contagious disease.¹ Thirty years ago, one of the authors was familiar with similar situations occurring with hospitals in upper state New York with Canadians who arrived for treatment that was denied in Canada. The hospitals stabilized these persons, and then found it more cost effective to pay for an ambulance and transport the patient back across the border rather than operate or perform expensive procedures that were not covered in Canada. While these patients were not contagious, they were requesting treatment that was either denied in their home country or treatment for which there was a long wait. The Canadians were hoping that the United States government would pay for care. Today, if a person with a life threatening injury arrives at the emergency department of a United States hospital that receives federal funding, the hospital is required to screen, assess, and possibly treat that person, regardless of ability to pay.² This requirement of the Emergency Medical Treatment and Active Labor Act (EMTALA) was originally proposed to prevent patient dumping.^2,3 Once the person is stabilized however, the hospital no longer has an obligation to provide free care. Money is the issue with this case study. The hospital has paid more than one million dollars in caring for Mr. Rivera and anticipates much more with an extended rehabilitation. Because he is now stable, they want to repatriate Mr. Rivera to his homeland.

Physicians and nurses provide care, typically without concern of who is paying for it. The first provision in the American Nurses Association’s (ANA) Code of Ethics for Nurses states that “the nurse , in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems”.^4p7 The American Medical Association’s (AMA) Code of Medical Ethics states that “A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights”.^5p306 Both the ANA and the AMA developed these codes of ethical statements primarily to benefit patients and other recipients of care. While both of these codes are not laws, they are professional standards of conduct that physicians and nurses have made a commitment to uphold. Practicing with these codes as guidelines, it is assumed that physicians and nurses will be practicing ethically. What happens when institutional decisions are made that conflict with professional codes of ethics?

Physicians and nurses respond to persons involved in situations such as this in various ways. Typically physicians are resentful of any legislation that seems to prescribe how they will screen, diagnose, or treat patients. Nurses typically don’t want to get involved in the financial aspect of treatment and just want to care for patients. Administrators want to abide by regulations to keep federal funding flowing. Patients want to receive the best possible care available regardless of cost.

An ethical dilemma exists when a situation has two equally undesirable options or when ethical principles conflict with one another. Medical repatriation is such an ethical dilemma. Many ethical principles are involved in this hypothetical dilemma and health care providers must decide which ones take precedence over others. There is a paucity of literature as to how nurses and physicians respond to medical repatriation.

The specific aims of the study were to:

1. Determine how physicians and nurses respond to a situation involving medical repatriation in one south Florida hospital and ascertain if there are any significant differences between the responses of physicians and nurses.
2. Examine if any variables significantly affect physicians’ and nurses’ responses to a situation involving medical repatriation.
3. Assess whether prior ethics training makes any difference in how physicians and nurses respond to medical repatriation.

Relevant Literature

There is a paucity of literature on the topic of medical repatriation such as depicted in this hypothetical case study. Most of the articles deal with repatriation due to a medical necessity rather than for financial reasons as cited in this scenario. The Emergency Medical Treatment and Active Labor Act (EMTALA) is important to review as all healthcare providers working in clinics and emergency rooms may be affected by the intent of the law. The EMTALA was proposed as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986.^1,2 The main purpose was to prevent hospitals that received federal funding from refusing to treat individuals who couldn’t afford to pay for medical services. Official wording refers to emergency medical departments, not in-patient units. Once stabilized, patients may be transferred to other facilities for further treatment.

Some noncitizens are sent back to their home country for strictly medical reasons and some are deported due to a financial drain on the United States The case study of Christina Imparato involved both reasons. She was refused admittance to the United States through Ellis Island due to trachoma (an eye infection) and because of the growing burden “on the purse of caring for immigrants who were chronically ill”.^1p227 In the late 19th and early 20th centuries, when immigrants were seeking entrance into the United States and deemed ‘unsuitable’, either for physical or mental impairment, they were sent back to their native land. United States immigration laws in effect during that time mandated that steamship companies provide free passage back to the port of embarkation.¹ Today, if hospitals or clients themselves want to or are required to return home, there either must be insurance to cover the repatriation or someone has to pay.^6,7

A study of Dutch citizens who were medically repatriated involved 115 persons who were aeromedically returned to the Netherlands. These patients were not sent home due to the inability to pay medical costs in the countries they were visiting, but by choice to receive care in their home country. Repatriation by air was essential as these worldwide travelers required specialized transportation due to exacerbations of chronic illnesses, severe illness, or traumatic injuries.⁶ These patients voluntarily returned home to receive what they felt was the best possible care.

Other countries face similar issues and discuss individuals living at the ‘social margin'⁸ and the impact on families when facing deportation.⁹ Because Mr. Rivera did not have a family, deporting him is even more problematic because of the question of who is going to assist with his care once he is discharged. As a bilateral amputee, he will need initial assistance with home care. This scenario doesn’t mention that anyone is familiar with home health care agencies in Honduras.

This study was guided by the theoretical rationale that ethical reasoning is central to making ethical choices and acting in an ethical manner. Unfortunately, knowing what choice is ethical and right does not always lead to acting in an ethical manner and making a right decision. One of the components of being a professional discipline is having a Code of Ethics. As members of professional disciplines, physicians and nurses abide by their respective codes.^4,5 Ethical reasoning involves using ethical principles in the decision making process. These principles are beliefs and values that guide professionals in making decisions. A background of ethical principles in practice is presented as principles ground the practice of medicine and nursing. Principles used in everyday practice include autonomy, confidentiality, beneficence, nonmaleficence, veracity, fidelity, and justice. Autonomy refers to self-determination and the right to make decisions that are free from controlling influences that are best for oneself.^5,10,11 Autonomy means respect for persons regardless of their nationality or inability to pay healthcare costs.⁴ The Hippocratic Oath, the Nightingale Pledge, and the ANA Code of Ethics all address privacy and confidentially and state that patients’ personal information remain confidential. This principle is essential to the provider-patient relationship. Patients have the right to expect that any information about their person or care is respected and private.¹⁰ “The Health Insurance Portability and Accountability Act (HIPAA) was enacted in 1996 to protect the privacy, confidentiality, and security of patient information.”^5p54

The principle of beneficence is the reason why most healthcare providers go into the field: to do good and serve others. Beneficence requires positive action to do good.^5,10,11 The Code of Nursing Ethics states that the nurse’s primary commitment is to the health, welfare, and safety of the client.⁴ Related to beneficence is nonmaleficence which is the basis for all ethical codes: that of doing no harm. In many healthcare situations, the harm must be weighed against the potential benefit.^10p49 An example of this may be that in giving chemotherapy to a cancer patient (beneficence), the patient has terrible adverse effects such as nausea, vomiting, and ultimately alopecia (nonmaleficence). The benefits of the chemotherapy must be weighed against the risks.

Veracity is an obligation to be truthful.^5,10 Keeping the patient informed at all times helps the patient with autonomous decision-making. The principle of fidelity “is the virtue of faithfulness, being true to our commitments and obligation to others”.^5p13 In healthcare, all providers need to remain true in following their respective codes of ethics.

Justice is probably the easiest of the ethical principles to understand, but the hardest one to carry out in healthcare. Justice involves fairness in the distribution of benefits and risks along with the allocation of scarce resources. In times of dwindling resources, it is hard to be just when financial considerations play such an important role. Dilemmas involving scarce resources cause daily conflicts with this principle. “Distributive justice is a principle requiring that all persons be treated equally and fairly. No one person, for example, should be given a disproportionate share of society’s resources or benefits”.^5p30

Methods

Research Design

A descriptive correlational design was used in this exploratory study to determine the relationships between the variables and the choices made by physicians and nurses to the responses in a hypothetical case study on medical repatriation.

Sample

A convenience sample was recruited among physicians and nurses in a for-profit hospital in South Florida. Of the 93 persons willing to complete all the components of the questionnaire, 67 were nurses and 26 were physicians. Seven (27%) of the physicians were females, and 6 (9%) of the nurses were males. The frequency of the other variables can be seen in Table 1.

Instrument

A case study was developed through conversations occurring at several ethics board meetings at a for-profit hospital in South Florida. With thousands of illegal aliens working in many migrant camps, situations involving care to injured workers occur frequently. It was not known how physicians and nurses felt regarding this topic. This was the impetus for the development of this case study. The nurse researcher developed the scenario and the corresponding questions, then shared it with the members of the ethics committee. After several minor revisions, the questionnaire was given to 10 different nurses to determine the ease of understanding the questions and to ask for any input for clarification.

Procedure

Approval was obtained from a University Institutional Review Board (IRB) as well as from the Ethics Committee of the hospital. Support was also granted by hospital administration, including approval of the medical and nursing staffs. Two hundred packets were distributed to several locations around the hospital. Packets included an introductory letter from the nurse researcher with informed consent information, a demographic questionnaire, the case study, and a return envelope. Physicians and nurses voluntarily took the packets to complete. Ninety three (48%) packets were returned within one month after distribution. It was initially thought that the majority of packets were returned. Upon realization that only half were returned, the researcher implored a Director at the hospital to inquire why more weren’t completed. Some of the responses included: “It must be somewhere on my desk; “It looked very interesting, but I just didn’t have time to complete it”; “I completed the questionnaire, but then wanted to add additional information and never got around to it”; and, “Is it too late?”

Data Analysis

Descriptive statistics were used to measure participant characteristics with all the variables as well as the numbers of persons choosing the different responses to the dilemma. Variables included; the participants’ educational level, gender, years of experience, ethnicity, religion, formal ethics training, and prior moral distress. Chi Square tests of significance were done to assess the relationship between the variables and the choices made to the responses to the case study. Ethnicity was the only variable that was statistically significant related to one of the responses to the dilemma.¹⁶

Findings

Table 1 shows the responses to the demographic questionnaire. Two final questions were included: Have you had any formal ethics training; and have you ever experienced moral distress in the outcome of an ethical situation? While some of the respondents stated that they had several hours per year as part of continuing medical education (CME) or continuing education units (CEU), 54% stated that they had no ethics training whatsoever.

Table 1

Participant Characteristics (N=93)

Note^a Totals may not equal 100% because of rounding

Over one half of the participants reported they had never experienced moral distress related to the outcome of an ethical decision, but 34% stated they had.¹⁶

There was no significant difference between physicians’ and nurses’ responses to whether or not Mr. Rivera should be medically repatriated. There were three choices to select following the case study which concluded with an open-ended question. The three responses with the number of persons choosing each one can be seen in Table 2.

Table 2

Participant Characteristics (N=93)

*p<.01

Notes:

^a Twenty-one percent of the total sample, eighteen percent of the nurses, and thirty one percent of the physicians selected 1, for example.

^b Percentage of total sample (93)

Almost 78% of the nurses and 65% of the physicians thought Mr. Rivera should be medically repatriated as soon as possible (Response #2). Almost 18% of the nurses and 31% of the physicians thought Mr. Rivera should stay in the United States and have the hospital absorb the cost (Response #1). Sixty-eight percent of men thought Mr. Rivera should be medically repatriated. Twelve females or 18% thought Mr. Rivera should stay and the hospital should absorb the bill. Seven or 28% of males felt the hospital should absorb the bill.

Responses to the second statement of sending Mr. Rivera back to Honduras as soon as possible was significant (p<.01) for ethnicity. Eighty-five percent of Asians, 80% of Caucasians and 75% of Hispanics said to medically repatriate Mr. Rivera. None of the African Americans said to do so. They all said that the hospital would have to ‘eat’ the expense.

There was one additional comment and question at the end of the case study: Obviously health care reform and immigration issues need to be addressed in the long run. This case study involves an immediate issue. What do you suggest be done immediately for Jose? Almost half (n=44) of the respondents wrote additional comments. These comments involved three separate areas: the drain on the economy from illegal immigrants; the suggestion that many more resources need to be explored; and the humaneness of care needed.

Illegal immigrants’ impact on the economy

Some of the comments stated that “our economy cannot continue to afford to support healthcare coverage for illegals by people who have not worked or supported this country’s economy”. One said that “the operative word is illegal”. Another stated that “It is unfortunate but our country can not spend resources for illegals while citizens and legal immigrants can not avail of the same care being given to illegals.” One comment was that “this country can not take care of its own, why should we take care of someone else?” One final statement was that “It is regrettable that the hospital is unable to ‘eat’ the cost, but the reality is that many other patients will not be able to get care if the hospital has to close due to the inability to stay open due to lack of monies”. This conflict relates to the principle of justice or fairness.⁵

Explore more resources

One respondent stated that if Mr. Rivera was here illegally, that “Honduras should have to pay at least half of his expenses and then punish him accordingly upon return to repay his country for expenses”. Another agreed that we should “transfer the patient at the receiving country’s expense”. Several respondents thought that the hospital should investigate international medical support groups. Others questioned whether the employer had workman’s compensation and questioned what the consequences are of the employer for hiring illegal immigrants. Many stated that the hospital should seek a rehabilitation facility that would take care of him on a charity basis. One person stated that this was defiantly a case for the Hospital Ethics Committee. Another comment referred to the fact that “Hospitals receive tax benefits for taking care of indigent patients so they should honor their obligations”. One respondent referred to individuals and their lack of political involvement being responsible for lack of resources—“If hospitals have rules/laws that dictate how each individual is to be treated regardless of ability to pay and those same institutions (including those people who work there) do not actively participate in this country’s political process and help make positive changes then yes, we should ‘eat’ the expense.” In this situation, the patients’ right to self-determination and autonomy is “being compromised because of a third party’s wishes for the patient.” ^5p25

Humaneness of care

Several respondents referred to the fact that Mr. Rivera was a hard worker (unlike some citizens). “Jose should get Medicare/Medicaid as he is or was a hard worker in the United States and deserves the same treatment as an American citizen”. One implored that “there must be a charitable organization that would care for persons like Jose. Maybe professionals volunteering their time and skills to take care of the less fortunate”. Many felt that he should “be treated with respect and proper care continued until he is able to be with his family or friends and he is back in Honduras”. This is beneficence in action.^5,10

Three final comments related this situation with similar problems occurring in hospitals. “What about the illegal immigrants crossing borders to deliver a child and then state that the child is now an American?” Another stated that Mr. Rivera was no different than the 27 year old type 1 diabetic, born in American, who is currently noncompliant, not trying to work and not paying taxes who is soaking up medical resources several times a year when he’s admitted to an ICU for diabetic ketoacidosis (DKA)”. One additional comment/question was that “criminals in jail are not even forcibly deported but hospitals can do this to a person in an unfortunate situation?” These comments relate to veracity and fidelity and further confuse a complicated problem.^5,10,11

Discussion

Physicians and nurses are expected to reason morally, act ethically, and practice expertly. That is a tall order in these times of dwindling resources when healthcare providers are expected to do more with less. There are many guidelines available to assist individuals with analyzing an ethical dilemma. One such framework involves using the mnemonic ETHICAL to provide a systematic way to allow reason rather than emotion guide one’s actions.¹² The letter E is for examining the date; T for thinking about which persons(s) should be making the decision; H for humanizing the options by constructing a decision tree; I for incorporating the ethical principles, legal statutes, standards of care, etc.; C for choosing an action; A for acting; and L for looking back and evaluating whether or not your choice worked and what should be done differently next time.¹² In addition, using conventions as predominant decision making criteria assists in the goal of reasoning at a principled level.¹³ The dilemma presented in this case study, while involving many personnel, is an institutional dilemma and ideally should be taken to the Ethics Committee to explore all options available involving multiple resources. As Mr. Rivera wants to remain in the United States to receive the best treatment, his autonomy is being taken away. The institution made an implicit agreement to care for him when he was admitted and the fidelity of that agreement is now compromised. While transferring Mr. Rivera to Honduras is in the best interests of the hospital (beneficence), it is harmful to him (nonmalificent). The care in the rehabilitation facility in Honduras is unknown and when he is discharged as a bilateral amputee, who knows what the home situation will be like.

President Obama in his ‘The First 100’ speech at the Presidential news conference on April 29, 2009 said that we have a “broken immigration system”. Mr. Rivera couldn’t agree more. While Mr. Rivera didn’t have any family in this country, his family would certainly be affected with his return to Honduras and his ultimate discharge from the rehabilitation facility in that country. Nijhawan⁸ and Hoffman⁹ discuss the impact that repatriation has on families. Nijhawan⁸ shares that several individuals have committed suicide rather than be sent back to their home country. Hopefully rehabilitation was started from day one in the hospital to help Mr. Rivera visualize his future and what he will be capable of doing with his limitations.

Nathaniel’s grounded theory of moral reckoning in nursing is another guide that may assist healthcare professionals to reflect on a troubling dilemma.¹⁴ This midrange theory involves three separate stages that guide the healthcare provider through the morally distressing situation beginning with the stage of ease where one is conflicted with the values learned in school, the institutional values, and the desire to follow the profession’s code of ethics as well as personal principles. The ANA and AMA Codes require both physicians and nurses to care for the patient regardless of his/her economic status and respecting the patient as person. A situational bind occurs that interrupts the stage of ease and in this case, it is the threat of discharging Mr. Rivera to a rehabilitation facility in Honduras because of financial considerations. The second stage of resolution is when the healthcare provider deals with the internal conflict. At this stage, providers can either make a stand or give up. Regardless which stance the physicians or nurses take, the institution has already made a decision to deport Mr. Rivera back to Honduras. The healthcare providers feel helpless in this situation. The stage of reflection is when the healthcare providers reckon their actions.

The one significant finding in this study was that the majority of all ethnic groups felt that Mr. Rivera should be repatriated except for all of the African Americans who felt that he should stay in America and the hospital would have to ‘eat’ the expense. There were only 3 African-Americans who completed the study so the strength of this finding is questionable. Future research needs to be done on the effect of ethnicity and how that plays a part in moral decision making.

In order to continue the moral work that physicians and nurses do, they must not be conflicted continually with moral distress. The respondents in this study stated that 34% of them had experienced moral distress in the past. There is enough stress in everyday work to get through that healthcare providers can’t afford extra stress. This last stage in the theory of moral reckoning involves examining the conflicts and seeing what could have been done differently and how providers can live with their decisions.¹⁴ As this institutional decision was already made, going to the Ethics Committee might have given physicians and nurses a voice in the institution’s decision and have them heard regarding future decisions involving similar cases. Physicians and nurses need to feel like they are making a difference in the lives of those they care for in order to proceed with the moral work that they do on a daily basis.

There are many resources that physicians and nurses must use in order to feel good about a decision that they or their institution has made regarding patients that they care for. When conflicts occur and their codes of conduct are in question, healthcare providers should access the Institutional Ethics Committee. The Committee could explore other resources for care that may be available for Mr. Rivera. Cases like this will probably occur in the future and physicians and nurses should learn from the outcome of this case what works and what doesn’t work in order to benefit patients in the future and to resolve any internal conflict. As moral distress is becoming more common every day and it has been documented that nurses resign positions because of moral distress, strategies must be addressed to decrease the moral distress in order to retain nurses.¹⁵

54% of the respondents in this study stated that they had never received any prior ethics training. While the question was geared to professional ethics training, such as a college course for credit, many did refer to CMSs or CEUs. It is still overwhelming that the majority hadn’t even received this minimal amount of ethics training. Institutions should conduct ethics training as part of the outreach of their Ethics Committees. This might also help with nurse retention due to moral distress.¹⁶

It was not surprising that there was no significant difference between physician and nurse responses to this dilemma. Many times physicians and nurses react to situations with their own mindset thinking of their different educational backgrounds and different experiences. In this small study at least it is reassuring that both groups think more alike than different. With this in mind, the hospital, through the ethics committee, could have several classes related to ethical theories and principles for physicians and nurses to attend together. Most educational classes in hospitals are conducted for each group individually. If physicians and nurses are to perform their moral work together, they should learn together. With similar codes, similar guidelines, and a similar ethic of care, together as one group, they might make some inroad into the chaotic healthcare environment that exists today which will positively affect patient care.

The results of this study can not be compared with the current literature as there are no studies that could be found on how physicians and nurses respond to the issues of medical repatriation. As this scenario is likely to continue in the future, research should be done to examine the issue involving a larger geographic area.

References

1. Imperato, P.J. & Imperato, G.H. (2008). The medical exclusion of an immigrant to the United States of America in the early twentieth century. The case of Cristina Imparato. Journal of Community Health, 33, 225-240. DOI 10.1007/s10900-008-9088-6. Published online, retrieved 4/27/09.
2. Thorne, J.L. EMTALA: The basic requirements, recent court interpretations and more HCFA regulations to come. Accessed from the American Academy of emergency Medicine. http://www.aaem.org/emtala/watch.php. Retrieved 4/27/2009.
3. Grimm, J.W. & Wells, J.L. (2009). Illegal immigrants in the emergency Department: An ethical dilemma for nurses? Journal of Emergency Nursing, 35(2), 127-128.
4. Code of Ethics for Nurses with Interpretive Statements. (2001). Washington: The American Nurses Association.
5. Pozgar, G.D. (2010). Legal and Ethical Issues for Health Professionals. Boston: Jones and Bartlett Publishers.
6. Greuters, S., Christiaans, H.M.T., Veenings, B., Loer, S.A., & Boer, C. (2009). Evaluation of repatriation parameters: Does medical history matter? Journal of Travel Medicine, 16(1), 1-6.
7. Carlson, J. (2008). Someone else’s problem: CEO exits Martin Memorial in midst of deportation lawsuit. Modern Healthcare, 38(39). #2010075253, accessed from CINAHL. Retrieved 4/29/09.
8. Nijhawan, M. (2005). Deportability, medicine, and the law. Anthropology & Medicine, 12(3), 271-285.
9. Hoffman, F.A. (2006). The impact of pressure on drug treatment for addicted foreigners facing deportation in Germany. Journal of Ethnicity in Substance Abuse, 5(1), 23-38.
10. Burkhardt, M.S. & Nathaniel, A.K. (2008). Ethics & Issues in Contemporary Nursing. N.Y.: Delmar Cengage Learning.
11. Beauchamp, T.L. & Childress, J.F. (2001). Principles of Biomedical Ethics. (5th Ed.). N.Y.: Oxford University Press.
12. Winland-Brown, J.E. (2007). Chap. 22 Ethical and legal issues of a caring-based practice. In L.D. Dunphy, J.E. Winland-Brown, B.O. Porter & D.J. Thomas, Primary Care, The Art and Science of Advanced Practice Nursing (1170-1183). Phila: F.A. Davis Co.
13. Dierckx de Casterlé, B., Izumi, S., Godfrey, N.S. & Denhaerynck, K. (2008). Nurses’ responses to ethical dilemmas in nursing practice: meta-analysis. Journal of Advanced Nursing, 63(6), 540-549.
14. Nathaniel, A.K. (2006). Moral reckoning in nursing. Western Journal of Nursing Research, 28(4), 419-438.
15. Pendry, P.S. (2007). Moral distress: Recognizing it to retain nurses. Nursing Economics, 25(4), 217-221.
16. Winland-Brown, J.E., & Dobrin, A.L. (2009). A comparison of physicians’ and nurses’ responses to selected ethical dilemmas. Forum on Public Policy Online. http://forumonpublicpolicy.com/spring09papers/archivespr09/winland.brown.pdf.