Chapter 5 : Nursing and Ethics

Section. Readings


Philip A. Pecorino

Process, Vol. VI. No. 2. (Summer, 1980), 13-17.

Modern science and technology not only present a challenge to contemporary religious faith but also in a much more subtle and pervasive fashion they threaten to undermine the basic values often associated with religious beliefs and practices. The crises in values is witnessed in the myriad of contemporary ethical issues and the growing awareness that society is not doing enough to prepare its members, especially its professionals, technicians, and business and political leaders to handle situations that pose moral problems. This article deals in particular with what is known as nursing ethics; however, the more general remarks are applicable to other fields as well.

Consider the following situation. The development of prenatal testing of fetuses (amniocentesis) which supplies knowledge concerning a number of abnormal fetal conditions coupled with the development of abortion procedures that hold low risk for the mother present women, and in some cases men, with the decision of whether or not to terminate the pregnancy "because" of the presence of an actual or merely a possible (especially in the case of sex-linked recessive genetic diseases) abnormal fetus. There are some who do not see the moral problems involved even in the case of the merely possibly abnormal fetus. The acceptance of the scientific, supposedly objective, or even merely statistical designation of abnormality appears for some at least to settle the issue. "Abnormal" is equated with "unacceptable" and to be avoided, even perhaps, at all costs.

Some are not sensitive to or do not appreciate the ethical issues involved. The value of human life, even an "abnormal" human life, appears to be displaced by another "higher" value or removed from consideration by some thought process that does not explicitly involve ethical considerations.

However, this situation presents a moral dilemma for the pregnant woman that did not exist before the availability of scientific-technical procedures. The woman must answer the many questions involved and they are to be answered at a time that highly values scientific productions and technical progress. The concerns and pressures on the woman are great and include, among others, society's desire to avoid another burden (care of abnormal children), especially if it is an "unnecessary" burden, which is equated with "avoidable."

As difficult as this situation may be to the pregnant woman involved, consider the nurse who attends the woman or who is asked to participate in or to administer the abortion procedure. The nurse's dilemma is often overlooked. It is taken for granted that the nurse will look after the welfare of the woman. The nurse is seen by some nurse- advocates as a patient-advocate who serves the needs of the patients. But just what are the proper limits to the nurse's concern? Is the nurse responsible for the physical welfare? The social? Economic? Spiritual? The nurse's role is defined in response to the answers to these questions. To the degree ‘that the nurse's responsibility is limited to the physical sphere, the nurse comes under the medical model of care. Is the woman pregnant with an abnormal fetus a patient? Is she sick? What is the illness, the disease? With only physical criteria to work with there is an abnormality and intervention is the generally accepted, even necessitated, response.

In a similar way several other situations confronted by nurses can be viewed. Take for example the existence and use of life support machinery and chemicals and the question of whether or not to continue to preserve life of certain limited life processes. Human dignity, the right of self-determination, privacy, and the value of life itself are issues in such cases involving what is commonly mislabeled as the "right to die". In such situations, the nurse as well as the suffering person is involved with these issues: the patient-person directly and the nurse directly as one duty bound to respect the rights of others and the indirectly as the patient's advocate-protector.

Beyond such situations there are those which pose moral problems in a unique way to the nurse, as a nurse, and do not involve the person-client-patient in the same way. The nurse must decide whether to follow the physicians’ orders or not when the physician asks the nurse not to inform a competent person of the nature of the illness or to reaffirm a false diagnosis, or when the physician prescribes an excessive and potentially harmful amount of a medication. What is the nurse to do when threatened with the loss of position for refusal to follow the physician's instructions? What is the nurse to do while witnessing a physician or fellow nurse about to perform a harmful act upon a patient, whether out of ignorance, accident or misintention? Must the nurse always prevent harm? Must the nurse physically restrain the physician? Must the nurse report such incidents? What of the consequences to the nurse? To the patient? What are nurses to do who witness the systematic harming or jeopardizing of the

physical welfare of their clients (patients) by the health care facility? Must they stand by, politely protest, or actively intervene, even strike?

These later situations present problems unique to health practitioners, especially nurses, and they call into question what the nurse's role is within the medical institution and society. They call into question or place the values of individuals over against that of social institutions and individual rights and duties over against social roles.

The debate within the field of nursing and within the health care institution as to what the proper role of the nurse is or should be exacerbated by those who advocate that the nurse's professional concerns expand beyond the physical welfare of the patient. Such as expansion would present new sets of problems. If, for example, nurses are given responsibility for the social welfare of their clients, then their position within the social health care institution will become considerably altered. Will they then be able to advocate for their clients against the interests of the society which trains, licenses, and supports them or will they become part of the socialization process themselves? Is "Let's take our medicine" to be replaced by "Let's not burden our other children or our state"?

If nurses are, for example, to consider the economic welfare of their clients before they advise or take action, then there would be considerable political pressure within the medical institution whose continued existence in its present form depends upon economic factors. Physicians and hospital and nursing home administrators are not likely to accept such an expansion of the nurse's responsibility that might threaten to alter the very nature of the institution let alone the relative economic and political status of the various health practitioners.

If nurses are to consider the spiritual welfare of the human being the nurse cares for, perhaps the greatest threat is posed to the established institutions which train and expect nurses to function as a nurse only, to remain within the socially defined role, and in some way to separate themselves from, their greater role as human beings. How is it possible to have a human being surrender human rights, prescient for accepting the responsibilities one human being has toward another, and disavow basic duties as human beings? It happens in an advanced technological society that views individuals as their social roles define them and trains them as technicians to handle problems only in institutional settings. Consider that the questions in this case vis-à-vis the nurse have been posed with reference to the nurse as a nurse and not first as a human being. Astonishing as this may be to some, it is common to find in the public discussion a virtual denial of the basic human rights and duties of nurses.

How is it possible to have a human being surrender human rights, reject the acceptance of the responsibilities one human being has toward another, and disavow basic duties as human beings?

It is only recently that there has come the grudging acknowledgment that patients have rights but they are recognized in the "Patients Bill of Rights" as patients’ rights rather than basic human rights as applied to the medical situation. This document weakly and partially restores person-patient what had been illegally and immorally denied and usurped. The call for a nurse's "bill of rights" would equally overlook the existence of a more fundamental set of human rights and duties that nurses have as persons and that cannot be denied or suspended in the medical setting without the sort of consequences now in evidence in the discussion of the role of nurses, in the moral dilemmas faced by nurses, and the growing disaffection of large numbers of nurses with their profession.

The judgment often arises that the way things are not the way things should be. Often and especially in a democratic and technocratic society, there is a confusion in thinking that the way things are supposed to be is what the law provides for. In practice, many people, and especially technicians and professionals, do not acknowledge that what is legal is not always moral and what moral is not always legal. It may be legal to have an abortion but immoral, at least for some. It may be legal for a nurse not to interfere with a physician causing harm to someone, but immoral. It may be moral duty to help another understand as best possible the contingencies in a situation in order to make a responsible decision as to their welfare and for those for whom they are responsible. Yet the nurse may be reprimanded or dismissed for doing so.

Most moral issues confronted by professionals and technicians, by physicians and nurses, are not dealt with ethically at all, i.e.; with a deliberative reasoning process and explicit, ethical principles. Instead, moral problems are responded to reflexively with a simplistic self-defensive posture with self-interest as the primary value or routinely with a simplistic repetition of traditional procedures. Employing the stage theory of moral development of John Dewey or Lawrence Kohlberg most treatments of moral issues are at the pre-conventional stage characterized by self-interest, self-gratification, concern for rewards and punishment and reciprocity or at the conventional stage characterized by the desire to conform to the wishes of the group accepting its mores and customs as laws and wishing to uphold the order of the status quo. There is little evidence of post-conventional ethical thought amongst technicians, business executives, and professionals such as physicians and nurses in which an autonomous morality is adopted and in which the individual develops their own personal principles, develops a conscience and refers to higher order concerns for social and legal obligations and for human dignity.

The ways in which professional engage ion dealing with moral problems is influenced by the social environment which offers models for their behavior based upon sets of governing ideals, conceptual frameworks, and well-refined roles. According to one ethician, William, May there are at least three such models: code, contract, and covenant.

Individuals might respond to a moral problem by referring to a professional code of conduct. Such codes are often vague, seldom formally explained, mainly rules of etiquette and intended to have practitioners avoid legal difficulties and conflicts with colleagues. The codes usually make only the most general references to humanitarian interests and goals and in practice make such concerns appear gratuitous. Most often the codes foster a collegial model of mutual support that coincides with economic advantage and maintenance of monopolistic control. The codes provide for a minimum of conflict and maximize the possibility of aesthetic enjoyment of life. Few professional organizations provide much support for their members who suffer adverse consequences (loss of a job) for their stand in conformity with the moral code of the professional organization but in conflict with the self-interest of their colleagues. The nurse who refuses an incompetent physician's order that would harm a patient and is dismissed as a result is for all practical purposes left alone by the professional organizations in attempting to do anything about the injustice.

The codes have not been working well as of late for people have lost faith in the power of the professionals with their technical limitations and flaws. Past trust and success encouraged an increase in expectations which could not be met. The public as consumers are increasingly refusing to trust professionals. They are less willing to accept the paternalistic attitude of the specially trained technician, the physician or the nurse. Lack of trust, betrayal of confidence failure to demonstrate continued progress and errors have led to the consumer's demand for satisfaction, great clarity in the nature of the relationship of consumer-producer, client-agent, patient-physician. The contract model is now replacing and being urged as a replacement for the codal model. In a democratic society especially, the civilized resolution of differences is through the courts which rest upon laws and refer to the terms of the contractual agreements between parties. Within this model the parties must satisfy the terms of the contract – no more, or less. Morality is equated with legality. Conformity to the letter of the law is the ideal. Malpractice suits involving almost every profession are the single most effective force encouraging the adoption of a contractual model.

There is a third model, covenant, which could provide the basis for addressing moral problems, but it is one which requires some socially acceptable transcendent frame of reference in order to become operative. Such a consensus as to a transcendent source of value and rights and duties is difficult to obtain in contemporary democratic society with ethical and religious pluralism become relativism and the weakened force of religious beliefs.

However, such a model presents individuals as related in covenant with one another. This relation cannot be broken and it requires fidelity to the duties incurred because of the received gift of one's life, opportunities of growth, and continued prosperity. In the covenant model there is an existential element. Individuals undergo an ontological change in status from ordinary members of society to professional, for example, and it is not simply a nine to five occupation but a change in life status which, in return for the acquisition of specialized knowledge and skills and the privileges and benefits of that professional practice, one incurs an obligation to serve the welfare of the society that developed the talents and confers the benefits. In Judeo-Christian traditions, God is viewed as the ultimate source of the gift and corespondent obligations. The covenant model involves the transcendent setting for principles, values, and concerns that may serve personal reflection and ethical reasoning.

It further incorporates the fidelity ideal of the contractual model and the collegial ideal of the codal model but provides the basis for self-criticism and self-discipline within the professions since it provides a higher obligation than service and defense of one's colleagues. It not only permits but encourages individuals to report on misconduct of colleagues and to effectively guard against malpractice since the higher duty is toward the public welfare, humanity.

The formal preparation of technicians incorporates aspects of the codal model and the so-called ethical components of business, engineering, medical, and nursing texts have a good deal more to do with legal responsibilities and contractual obligations than with moral principles. There is little reference to values and the source of values that could serve as the transcendent reference for the covenant model.

There is a need for the introduction into the formal preparation, into the schooling or training of mechanics, technicians, professionals, bureaucrats, physicians and nurses of a truly educational component that would encourage the development of self-identity and the realization of potentiality. Opportunities ought to be provided for value amplification and clarification, ethical evaluation and deliberation, and aesthetic sensitization and elaboration.

The educational institution ought to acknowledge that most people do not live to work but work in order to live. The curriculum ought not just prepare someone for a job but for life. A curriculum that aims at preparing individuals for life ought to allow for and even require experiences intended to assist individuals in dealing with and incorporating the religious, philosophical, and artistic traditions that underlie culture. In fostering cultural appropriation self-realization would be promoted, while at the same time the individual would become aware that there are costs and benefits extending beyond the particular situation and involving more than self and that there are legitimate concerns beyond professional and institutional interest: concerns for principles, rights, values, and universal human welfare. The basis for the covenant model would thus be developed.

Throughout the nursing profession there has been an ever-growing awareness of ethical issues. At first, this was part of the general increase in awareness in ethical problems faced by all health practitioners and recipients (patients) and it continues to be the case that most of the ethical discussions among nurses involve the general issues in Bioethics or Medical Ethics rather than those specific dilemmas faced especially by nurses, as were indicated above. Recently there have been attempts to provide more ethical preparation for nurses. However, recent surveys reveal that there are very few courses in Nursing Ethics in the over l300 nursing schools in the United States. There are a few such schools in college settings where courses are purely elective. Moreover, reservations have been expressed about the need for an entire course, questions raised about its possible objectives, format, and its instructor's required background. There are few texts available and most have been published only within

n the last three years. Several others are presently being prepared for publication. There are courses in continuing education programs on various issues in medical ethics with a focus on nursing, but they are non-credit electives.

Occasionally, in service programs may have a presentation involving ethical issues. Most of the resolution of moral problems appears to be handled in informal discussions or through the matter of fact recapitulation of some similar case as if to imply that, as such cases have been handled in the past, they ought to be or will be in the future.

In the health institutions such as hospitals and nursing homes, it is extremely rare to find any individual or office or committee that is formally designated as assisting in the discussion and resolution of ethical issues or in preparing staff in handling such issues but recently some have been introduced.

Within the professional organizations there is growing interest in these issues and in the members’ ability to deal with them. The American Nursing Association and several affiliated state organizations have established committees or councils on ethical practice. State licensing agencies have review boards that deal with illegal and unethical practices. Several professional nursing journals regularly feature articles and columns that describe moral dilemmas and address themselves to the underlying ethical issues. There have also been a variety of regional and national conferences on Nursing Ethics. Laudatory as all this is, it has done little so far in terms of effecting the nursing community, let alone nursing practice. Further, the situation in nursing reflects and responds to the more general set of social instructional problems.

There is much that could be done in terms of ministering to the needs of those who are preparing to enter technical professions such as nursing. Not the least of these needs is the development of critical reasoning ability, moral principles, and ethical sensibility to assist them in facing moral dilemmas and ethical issues. Introducing applied ethics courses into the curriculum, sponsoring special programs addressing ethical issues, guest lectures on ethics in and out of the classroom, circulating articles treating ethical problems, raising the consciousness of faculty and administrators as to these needs, leading discussion sessions among students on ethical issues and many other activities would be quite helpful. The possibilities for responding to this call are limited only by the imagination. Any and all activities that bring human values to consciousness in an age of technology are most needed.

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© Copyright Philip A. Pecorino 2002. All Rights reserved.

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