Michael Yeo, Anne Moorhouse, Pamela Khan, and Patricia Rodney
A portion of the revenue from this book’s sales will be donated to Doctors Without Borders to assist the humanitarian work of nurses, doctors, and other health care providers in the fight against COVID -19 and beyond.
“One thing that sets Concepts and Cases in Nursing Ethics apart from many other nursing ethics texts is its effective weaving of theory into thoughtful discussions of case studies that have direct relevance to nursing. Student nurses and registered nurses should find much of value in the book’s ‘application to practice’ approach, which offers insights not only into the nature of ethics but also into the ways in which ethical analysis can help develop ethical nursing practice.”
—Derek Sellman, Faculty of Nursing, University of Alberta
“Ethical training is increasingly necessary in order to help nurses distill the concepts of right and wrong conduct. This text, in its fourth edition, provides nurses at various stages of their careers with basic ethical decision-making theory supplemented with timely and relevant case studies designed to show why value-based care is—and will always be—an integral component of effective health care.”
—Blair
Henry, Senior Ethicist, Assistant Professor at the University of Toronto
Concepts and Cases in Nursing Ethics is an introduction to contemporary ethical issues in health care, designed especially for Canadian audiences. The book is organized around six key concepts: beneficence, autonomy, truth-telling, confidentiality, justice, and integrity. Each of these concepts is explained and discussed with reference to professional and legal norms. The discussion is then supplemented by case studies that exemplify the relevant concepts and show how each applies in health care and nursing practice. This new fourth edition includes an added chapter on end-of-life issues, and it is revised throughout to reflect the latest developments on topics such as global health ethics, cultural safety, social media, and palliative sedation, as well as ethical issues relating to COVID- 19.
Michael Yeo is Professor in the Department of Philosophy at Laurentian University.
Anne Moorhouse teaches bioethics at Ryerson University and practices nursing at Sunnybrook Health Sciences Centre, Toronto.
Pamela Khan is Associate Professor, Teaching Stream, at the Lawrence S. Bloomberg Faculty of Nursing at the University of Toronto, and a member of the University of Toronto Joint Centre for Bioethics.
Patricia Rodney is Associate Professor in the School of Nursing and a Faculty Associate with the W. Maurice Young Centre for Applied Ethics at the University of British Columbia.
ISBN 978-1-55481-397-1
ISBN 978-1-55481-397-1
CONCEPTS AND CASES IN NURSING ETHICS
CONCEPTS AND CASES IN NURSING ETHICS
4 th EDITION
Michael Yeo, Anne Moorhouse, Pamela Khan, and Patricia Rodney
broadview press
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Title: Concepts and cases in nursing ethics / Michael Yeo, Anne Moorhouse, Pamela Khan, and Patricia Rodney.
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Edited by Tania Therien Book Design by Em Dash Design
PREFACE (Michael Yeo) 11
INTRODUCTION (Michael Yeo) 13
1. Outline of the Book 13
2. What Is Nursing Ethics? 14
3. Nursing Ethics, Bioethics, Health Care Ethics 15
4. Nursing Ethics and Nursing 17
5. Models of the Nurse-Patient Relationship 18
6. A Knowledge Base in Ethics for Nursing 20
7. Ethical Analysis and the Nursing Process 25
8. Case-Based Learning 29 References 30
CHAPTER 1: A Primer in Ethical Theory (Michael Yeo) 33
1. Morality and the Sense of “Oughtness” 34
2. Morality and Ethical Analysis 35
3. Accountability and Morally Principled Decisions 37
4. Ethical Analysis and Ethical Theory 38
5. Theories about Morality 40
6. Ethical Theories 45
7. Conclusion 62 References 64
CHAPTER 2: Beneficence (Michael Yeo, Anne Moorhouse, and Pamela Khan) 69
1. Beneficence and Benefiting Others 70
2. Beneficence, Self-Concern, and Duty 71
3. Challenges Determining What Is Beneficial 75
4. Paternalism 79
5. Beneficence: Caring for Individuals in Context 81
6. Conclusion 83
Case Studies
Case 1: Parens Patriae and the Case of J.J. (Michael Yeo and Anne Moorhouse) 84
Case 2: Disagreement about Treatment Decision-Making (Anne Moorhouse and Michael Yeo) 97
Case 3: Prescribed Opioids for Chronic Pain (Anne Moorhouse and Michael Yeo) 104
Case 4: Humanitarian Work in War-Torn Areas (Anne Moorhouse and Michael Yeo) 106
Case 5: Global Health, Cultural Differences, and Nursing Values (Michael Yeo, Anne Moorhouse, and Pamela Khan) 108
References 111
CHAPTER 3: Autonomy
(Michael Yeo, Anne Moorhouse, and Pamela Khan) 117
1. The Meaning(s) of Autonomy 118
2. Autonomy and Consent 125
3. Nursing Ethics and Consent 134
4. Limiting Autonomy: Paternalism, Protection of Others, and Justice 140
5. Autonomy, Advocacy, and Empowerment 156
6. Conclusion 160
Cases Studies
Case 1: Advocating on Behalf of Vulnerable and Voiceless Patients (Michael Yeo and Anne Moorhouse) 161
Case 2: Hassan Rasouli, Withdrawal of Life Support, and Limits of Autonomy (Michael Yeo and Anne Moorhouse) 166
Case 3: Scott Starson, Mental Illness, and Capacity to Decide (Anne Moorhouse and Michael Yeo) 175
References 180
CHAPTER 4: Truth-Telling and Truthfulness
(Michael Yeo, Pamela Khan, and Anne Moorhouse) 185
1. Truthfulness and Truth-Telling in Health Care 186
2. Arguments for and against Truthfulness in Health Care 187
3. Cultivating Good Judgment 192
4. Truthfulness and the Circle of Care 198
5. Conclusion 200
Case Studies
Case 1: Issue Concerning Communication of a Mental Health Diagnosis (Pamela Khan, Anne Moorhouse, and Michael Yeo) 201
Case 2: Cultural Values of Family Opposed to Informing Patient of Bad News Diagnosis (Pamela Khan, Anne Moorhouse, and Michael Yeo) 206
Case 3: Patient Request for Bad News Information in Trauma Centre (Anne Moorhouse, Pamela Khan, and Michael Yeo) 212
Case 4: Disclosing and Reporting a Patient Safety Incident (Michael Yeo, Anne Moorhouse, and Pamela Khan) 216
References 221
CHAPTER 5: Privacy and Confidentiality
( Michael Yeo, Anne Moorhouse, and Pamela Khan) 225
1. Health Professionals, Persons, and the Personal 226
2. Privacy and Confidentiality 227
3. Breaches of Confidentiality 228
4. Information-Sharing, Patient Authorization, and the Circle of Care 230
5. Determining Whether Information Is Confidential 232
6. Exceptions to the Rule of Confidentiality 233
7. Privacy and Confidentiality in the Digital Age 235
8. Privacy, Confidentiality, and Social Media 239
9. Conclusion 245
Case Studies
Case 1: Confidentiality in an Occupational Health Unit (Anne Moorhouse, Pamela Khan, and Michael Yeo) 246
Case 2: Disclosing Information to Patient’s Friends and Family (Anne Moorhouse, Pamela Khan, and Michael Yeo) 253
Case 3: Release of Confidential Information to Third Parties without Consent (Anne Moorhouse, Michael Yeo, and Pamela Khan) 258
Case 4: Nurse Privacy and Social Media (Michael Yeo, Anne Moorhouse, and Pamela Khan) 265
References 269
CHAPTER 6: Justice
(Michael Yeo, Anne Moorhouse, Patricia Rodney, and Pamela Khan) 273
1. Justice in the Distribution of Health Care and Resources for Health 274
2. Theories of Justice 275
3. Tensions and Conflict among Theoretical Orientations 277
4. Substantive Principles of Justice 278
5. Procedural Principles of Justice 284
6. Integrating Substance and Process 286
7. Levels of Resource Allocation and Decision-Making 287
8. Conclusion 296
Case Studies
Case 1: Tension between Access to Care versus Quality of Care (Anne Moorhouse, Pamela Khan, and Michael Yeo) 298
Case 2: Allocation of Clinical Placements and Support for Clinical Education (Anne Moorhouse, Pamela Khan, and Michael Yeo) 303
Case 3: Equitable Allocation of Nursing Time and Care (Michael Yeo, Anne Moorhouse, and Pamela Khan) 308
Case 4: Triage and Rationing of Intensive-Care Beds during a Clinical Crisis (Anne Moorhouse and Pamela Khan) 312
Case 5: Medical Tourism (Anne Moorhouse and Michael Yeo) 317
Case 6: Jumping the Queue with Private Health Care (Anne Moorhouse and Michael Yeo) 319
References 321
CHAPTER 7: Integrity
(Michael Yeo, Anne Moorhouse, Pamela Khan, and Patricia Rodney) 327
1. Integrity Defined 328
2. Personal and Professional Integrity 333
3. Integrity and Multiple Obligations 337
4. Integrity and Moral Distress 343
5. Conclusion: From Moral Distress and Disengagement to Co-Operation and Moral Community 347
Case Studies
Case 1: Conscientious Reflection about Exposure to Risk in Context of a Pandemic (Michael Yeo and Anne Moorhouse) 350
Case 2: Conscientious Objections to MAID at the Individual and Institutional Levels
(Michael Yeo and Anne Moorhouse) 356
Case 3: Hospital Overcrowding and Discharge Planning (Anne Moorhouse and Michael Yeo) 364
Case 4: Responding to Mistreatment of Patients in Correctional Facility (Michael Yeo and Anne Moorhouse) 366
References 368
CHAPTER 8: End-of-Life Decision-Making
(Michael Yeo, Anne Moorhouse, Patricia Rodney, and Pamela Khan) 375
1. A Comprehensive Approach to End-of-Life Care 376
2. Exploring the Ethical Debate and Controversy about Assisted Death 378
3. Carter v. Canada, 2015 391
4. MAID Nursing Practice Implications 398
5. Conclusion 403
Case Studies
Case 1: Margot Bentley and Advance Care Planning (Michael Yeo and Anne Moorhouse) 404
Case 2: Continuous Palliative Sedation Therapy (Michael Yeo and Anne Moorhouse) 417
References 422
ADDENDUM : Reflections on the Coronavirus Disease 2019
( COVID -19) Pandemic: June 3, 2020
(Michael Yeo, Patricia Rodney, Anne Moorhouse, and Pamela Khan) 429
Index 471
PREFACE
The third edition of this book began with a quote from the preface to the second edition: “Health care in Canada has changed dramatically in the five years that have passed since the first edition of this book.” This is now the fourth edition, and the changes in the Canadian health care landscape since the third are even more dramatic and an even more substantial revision was required for this edition. These dramatic changes include the COVID -19 pandemic, which occurred as this book was in the final stages of production!
The overall format of the text remains the same, organized around discussion of central concepts in ethics, with provocative cases that bring to life and probe each concept. The moral values, virtues and principles associated with each of these concepts remain as relevant today as ever, and these concepts continue to be a useful way to orient ethical reflection and analysis in relation to the ever-changing health care landscape. However, the analysis throughout this edition has been reworked in view of updated references from the literature and significant developments in nursing ethics, the profession of nursing, health care, health policy, and society more generally.
Most of the cases and commentaries are new; we have also taken the advice of one of our reviewers and included some cases without commentary for readers to work through on their own, guided by suggested questions. New topics have been added, including medical assistance in dying ( MAID ), palliative sedation, social media, and issues concerning Canada’s Indigenous peoples.
Given the extent of the revisions, this edition is as much a rewrite of the previous edition as it is a revision. Even so, in important ways it still bears the traces of the earlier editions. The voices of co-authors who contributed to the very first edition and were not involved in the preparation of this edition can still be heard. It is fitting here to acknowledge with abiding gratitude the work of these individuals: Trudy Molke (Beneficence); Jean Dalziel (Autonomy); Sandra Mitchell (Truthfulness); Irene Krahn (Privacy and Confidentiality); Gail Donner (Justice); and Ann Ford (Integrity).
I want to thank my co-authors—Anne Moorhouse, Pamela Khan, and Paddy Rodney—for their contributions and commitment to this edition. Putting this new edition together took longer (much longer) than any of us originally anticipated and required much more work. We are appreciative of the thoughtful comments and recommendations offered by reviewers of the previous edition. We are grateful to Broadview Press for their support and for their patience with our proposed timelines. We believe that the final product has been worth the wait.
Michael Yeo
INTRODUCTION
1. OUTLINE OF THE BOOK
The profession of nursing, like the health care system, is undergoing rapid development. New and diverse roles are emerging, and old roles are being redefined. The profession is becoming more reflective about the meaning of nursing. What is nursing, and what ought nursing to be? Such questioning is intricately bound up with ethics.
The aim of this book is to present a unified perspective on the ethical dimension of contemporary nursing. Its objective is to furnish nurses with a clearer understanding of the key concepts and arguments in which ethical issues in, or impacting on, nursing are interpreted, discussed, and analyzed. Such understanding will better equip nurses to face the challenges of their profession and to practise responsibly in their chosen fields and specialties.
The book is divided into eight main chapters and an addendum. The first chapter is a brief primer to introduce readers to ethical analysis and the main lines of thought in ethical theory. Chapters 2 through 7 are devoted to the elucidation of six concepts fundamental to ethical analysis and theory: beneficence, autonomy, truthfulness, privacy and confidentiality, justice, and integrity. Each of these concepts covers a value, principle, or virtue highly prized in nursing and more generally in health care. Virtually any ethical issue in nursing involves reference to one or more of these concepts. Ethical norms and guidance provided by professional nursing associations and regulatory bodies are referred to throughout as they bear on issues under discussion, as are legal frameworks relevant to nursing practice. In this edition, we have also included a chapter specifically devoted to end-of-life care. Recent developments with respect to palliative care and MAID warrant detailed and focused analysis as nurses and other health care providers orient themselves to practice implications that are still being worked through. In light of the COVID -19 pandemic, we have also
added an Addendum which offers reflections on the pandemic in light of the main value concepts discussed in the book.
Each chapter includes cases for reflection or discussion that highlight issues related to the concept around which the chapter is organized. Some of these are actual cases compiled from publicly available information or from landmark court cases; others are fictionalized, based on the authors’ experience with actual cases. Each case is preceded by an introductory preamble, which puts the issue raised by the case in context. Most of the cases are followed by a critical commentary in which ethical analysis is brought to bear; some are left without commentary so that readers can analyse the issue for themselves, guided by the background information and analysis in each chapter.
The chapters flow from one to another in sequence, but each chapter stands on its own and can be read selectively according to the reader’s interests. The book in its entirety is ideally suited for a dedicated course in ethics, but instructors may also find it useful to select individual chapters or specific cases to match whatever topic or subject students are learning in their curriculum. We hope that practising nurses will also find this book useful and that nurse educators will draw from it to facilitate reflection and conversation about various ethical issues being grappled with in hospitals and other organizations that provide health care.
2. WHAT IS NURSING ETHICS?
Nursing ethics can mean different things. Used in one sense, nursing ethics refers to the expressed moral norms of the nursing profession: the values, virtues, and principles that the profession believes should guide nurses in everyday practice. These are typically phrased as moral injunctions such as “be truthful with patients” or “respect patient confidentiality.” They may also be expressed as exhortations to adopt and practise particular virtues, such as caring or fairness. As publicly stated by the profession in codes of ethics, these norms serve not only to guide nurses in their practice and identity formation but also to inform the public about what they can expect from professional practitioners.
In another, related meaning, “nursing ethics” refers to a body of scholarship and research in books and professional journals that deals with the moral dimension of nursing wherein various ethical issues are analyzed, discussed, and debated. Used in this sense, nursing ethics refers not to the norms of the profession but rather to a field or discipline in which such norms are analyzed and debated.
3. NURSING ETHICS, BIOETHICS, HEALTH CARE ETHICS
Nursing ethics has developed alongside the much broader phenomenon of bioethics and health care ethics. Bioethics may be defined as reasoned enquiry about the ethical dimension of interventions in the lives of human beings directed to or bearing on their health good, individually or collectively. Health care is an obvious example of such an intervention, and in this regard bioethics is sometimes used synonymously with “health care ethics.” Issues of research and experimentation also are included in the field of bioethics.
Several factors bear on the emergence of contemporary bioethics and have influenced the development of health care ethics and nursing ethics (Rodney, Burgess, et al., 2013). The three described below are especially noteworthy.
3.1. Technological Developments
Rapid scientific and technological developments presented health professionals with new powers and treatment options, and with these, new ethical issues. The ventilator is a good example. It enabled the prolongation of life (or dying), but with this power difficult ethical questions arose. Equally poignant examples can be drawn from reproductive technology, transplantation, and genetics, to name only some of the more topical ones.
Technological developments outpace the capacity of existing ethical norms and present us with more and more confusing grey areas about which consensus needs to be forged through dialogue and debate. Scholars who work in ethics or on ethical issues—ethicists, philosophers, nurses, physicians, and other health care providers—attempt to think critically and systematically about these difficult grey areas in view of emerging evidence. This work contributes toward the goal of improved health and health care for individuals, groups, and society overall.
3.2. Research and Experimentation
The negative publicity about gross abuses in research involving human subjects that took place in Nazi Germany and questionable research practices in North America generated considerable discussion about ethics in research (Beecher, 1966, 1959). Should some categories of people—for example, children, captive populations, people who lack mental capacity to decide—be excluded from
research? What measures and controls will best ensure the voluntariness of research subjects? How do we decide acceptable ratios of benefit to harm, and who should decide on these ratios? Many of the main principles of bioethics such as informed consent, autonomy, and beneficence have been defined and redefined against this background. Significant progress has been made over time in the standards and application of both research ethics and bioethics.
3.3. Consumerism and Patients’ Rights
Throughout the 1960s, the idea of consumer education and protection took hold in North America, and the rhetoric of rights became more and more prominent in discussions about matters ethical (Fleming, 1983; Storch, 1982). Increased scrutiny was directed toward the health care system as a locus of considerable power. “Patients” increasingly came to view themselves as “consumers” or otherwise to expect a more active and controlling role in their care. An important landmark occurred in 1973 when the American Hospital Association introduced a twelve-point “Patients’ Bill of Rights,” which was subsequently translated into policy in numerous American and Canadian institutions. The rise of the patients’ rights movement occurred concurrently with rising public distrust of the authority vested in religion, government, scientists, and professionals. Increased scrutiny was brought to bear on the practice of health professionals, and with this came higher standards of public accountability. Many ethical matters once trusted to the discretion of professional authorities came to be designated as public questions. A new ethic emerged and took shape around the watchword “autonomy.” This was in part shaped by a growing cultural and political pluralism in which the values of individual rights and liberties ruled the day. The paternalism long entrenched in the health professions came to be widely criticized. Patients demanded to be more involved in decision-making regarding their health care. Broad legislative changes both reflected and shaped new public expectations about patient involvement in health care planning, the doctrine of informed consent being a prime example of this trend. Whatever public consensus existed on health care ethics was strained as new ethical issues came to the fore and old ones took on a new complexion and urgency.
Social developments along these lines opened up the space of questioning within which contemporary bioethics developed. Professional philosophers and theologians brought their traditions and skills to bear on the many ethical
questions and issues that were emerging, and health professionals became increasingly interested in moral philosophy and moral reasoning.
4. NURSING ETHICS AND NURSING
Several features of nursing have helped to shape contemporary nursing ethics. To begin with the most obvious, nursing has been predominately a woman’s profession, although the gender balance of the profession has shifted and continues to do so. Some authors, building from the premise that women (whether by nature, culture, or both) value such things as nurturing and caring more than men, have argued that an “ethic of care” may be especially appropriate for nursing. This point of view, and the assumptions that inform it, are a matter of debate, as we shall see when we discuss the matter in greater detail in chapter 2. Regardless, there is evidence that nursing, in contrast with the “medical model,” has been more oriented around “caring” than “curing.” Moreover, nursing has tended to work with a broader understanding of health than medicine. This has implications for the kinds of ethical issues that arise and how they are framed.
Gender has also been significant as concerns the value that society and other health professionals have attached to the work of nursing. It bears on such important matters as the drive for professionalism in nursing. Historically—and related to gender—nursing has been in a position of subordination in the health care system. It is instructive to recall the motto of the Mack training school for Nurses, the first of its kind in Canada: “I see and am silent” (Coburn, 1987).
The situation of nursing vis-à-vis power and decision-making in the health care system has been a focus of attention in nursing ethics since its early days. For example, Yarling and McElmurry (1986) argued that, under existing legal and institutional arrangements, many nurses did not have the freedom or power to practise ethically. The political dynamics of nursing have changed considerably, but in various ways organizational constraints and the distribution of power inform and shape many of the ethical issues nurses face in their daily practice (Rodney, Buckley, et al., 2013; Varcoe and Rodney, 2009).
Related to the distribution of power is the fact that many ethical issues arise because nurses often find themselves in institutional situations wherein they have multiple obligations. Notwithstanding the arrival of interprofessionalism and team care based on collaborative decision-making, the legal and
institutional horizon of nursing is such that nurses sometimes must contend and live with the effects of decisions into which they may have had little or no input, and with which they may disagree. Over the years, the profession of nursing has increasingly emphasized the importance of nurses, individually and collectively, taking active steps to make their practice environments more conducive to practice in accordance with ethical ideals.
Another feature constitutive of nursing ethics is what Storch called “being there” (1988, p. 212). Nursing care is less episodic than that provided by other health professionals. In a hospital setting, for example, physicians may come and go but nursing is there for the patient around the clock. Other health professionals tend to get unconnected snapshots of the patient whereas the nurse gets a full-length movie version. The contact between the nurse and the patient is such that many dimensions of the patient’s being are disclosed in the relationship.
The duration and nature of his or her contact with the patient make it possible for the nurse to know the patient somewhat more intimately than do other health professionals. This holistic experience of patients bears on a number of ethical matters. For example, it is one thing to witness the distress of someone whom one knows only superficially, and another to witness the distress of someone with whom one has established a closer relationship.
5. MODELS OF THE NURSE-PATIENT RELATIONSHIP
The ethical landscape of nursing appears differently depending on how the relationship between nurse and patient is viewed. We will present three main models for thinking about this relationship.
5.1. The Contractual Model
Following the contractual model, the nurse and the patient negotiate the moral parameters of the relationship and through dialogue make explicit what each expects from the other. Does the nurse or the patient have any special values likely to come into play in the course of the relationship? How involved does the patient want to be in care planning? What family members or friends are to be consulted should the occasion arise? In the course of discussion, either the nurse or the patient may find that the other has unacceptable
expectations or demands. If so, it is best that this be known in advance of any issues that might arise.
The shared understanding thus negotiated can be thought of as a kind of “contract” that serves as a guide and reference point for whatever ethical decision-making may be required in the course of the relationship. A shared understanding builds trust in the relationship because each person knows what to expect from the other. It also empowers the patient by creating a sense of control at a time when he or she may be disoriented by illness and by being in a foreign environment. The preference that many nurses have for the word “client” in place of “patient” is in keeping with the empowering spirit of the contractual model, emphasizing as it does the agency of the client/patient and the voluntary element of the relationship.1
5.2. The Patient Advocate Model
The role of patient or client advocate has been adopted and endorsed by nursing to a far greater extent than by other health professions. The term “advocate” itself is imported into health care from law. It came into vogue with the emergence of consumerism and the patients’ rights movement in health care. To advocate in the context of health care is often taken to mean advocating on behalf of the patient’s rights, such as the patient’s right to be adequately informed about treatment options or to access information in his or her health record. Patients may not be aware of their rights, in which case advocacy can mean informing or educating patients about their rights. In other cases, such as if the rights of a patient are being ignored or overlooked, advocacy can mean going to bat for the patient or advancing the patient’s rights and interests with one’s colleagues or one’s institution. This can be especially important in the case of vulnerable patients who are overwhelmed by their condition, or the experience of being in an institution in which they are not at home, or who otherwise are not able to speak for themselves.
The rights-based model of advocacy has an important place in nursing and can be a valuable corrective in situations where patient autonomy is at risk of being eclipsed by paternalism (someone else imposing upon the patient their beliefs about what is good for the patient), or in which the patient is at risk of
1 We use the term “patient” throughout this book as our default. However, when discussing quotations from sources that use other terms, such as “client” or “individual” or “person,” we use the source’s term in that context.
being lost sight of in the system. However, rights-based advocacy has shortcomings. The emphasis on rights can overshadow other important aspects of the experience of being a patient. Gadow (1980, p. 84), although sympathetic to the growth of the patient’s rights at the time, criticized the representation of the patient in one-dimensional, abstract terms as a bearer of rights. In place of rights-based advocacy she suggested the term “existential advocacy,” directed to the patient as a whole being.
5.3. The Social Justice Advocacy Model
The models we have described to this point are premised on a one-to-one relationship of an individual nurse advocating for an individual patient. While the models capture important dimensions of nursing roles, they do not tell the full story. In particular, they do not address the reality that individual nurses typically work collaboratively with other nurses and health professionals in providing care to patients, and these collaborative relationships can complicate a nurse’s relationship with patients. In some cases too, such as in public health, the nurse does not have a single person as a patient or client but rather a family or even a community on whose behalf he or she advocates.
As well, these models do not capture the roles that nurses play in broader social contexts—ways in which nurses undertake to address system-level issues that bear on access to care and quality of care, and on the health of populations. Emphasis on the role of nurses in addressing system-level issues has become increasingly prominent in the profession. For many nurses today, the understanding of what it is to be a nurse and to be an advocate goes considerably beyond relationships with individual patients to include social and political action in the name of social justice and human rights (Anderson et al., 2009; Canadian Nurses Association, 2017).
6. A KNOWLEDGE BASE IN ETHICS FOR NURSING
Having described the context in which contemporary nursing ethics has developed, what does all this mean to the individual practising nurse? A helpful way of focusing this question is to ask what knowledge base in ethics is appropriate for nurses. There is room for debate around this question, but the nursing ethics literature reflects consensus around at least three main areas
of knowledge and reflection: (1) moral beliefs and values; (2) relevant codes, policies, and laws; and (3) fundamental concepts of moral philosophy.
6.1. Moral Beliefs and Values
Through our upbringing and acculturation—the influence of family, peers, and so on—we acquire beliefs about right and wrong and good and bad. Beliefs thus acquired are deeply constitutive of who we are as adults and may manifest themselves in our actions without our ever having reflected upon them. We may not realize how these beliefs express themselves in our lives until challenged by others. The ethical life commits one to bringing such unexamined or unreflected-upon beliefs to light and, having clarified them, to explicitly and responsibly embrace, reject, or modify them.
The task of acquiring self-knowledge may also be expressed with reference to “values” rather than to “moral beliefs.” Values clarification is a process of becoming more aware and reflective about the values that have been inculcated in us through various influences. This enables us to decide in a self-conscious way what values we ought to prize and promote, to assess how various practices stand in relation to these values, and to shape our professional identities in accordance with the ethical values proclaimed by the profession.
Intervention in the lives of others with respect to matters about which they care and value deeply carries tremendous responsibility. In nursing, such intervention is mandated and legitimized in the name of health and health care. Therefore, health is the most obvious value that matters in the health care context. However, beneficent concern for the health of the patient may come into conflict with several other, sometimes competing values, such as autonomy, truthfulness, confidentiality, and justice.
Where values are concerned—where things about which people care deeply are at stake—one whose professional promise is to benefit and respect the patient must acquire a certain facility in moving within the dimension of values. This means, first of all, becoming sensitive to the values dimension of nursing. At every step in the nursing process questions of value should be raised, if only to ask “Are there any questions of value to be considered here?” This is not to say that every nursing intervention, however routine, will raise an explicit ethical issue requiring an explicitly ethical decision. Indeed, few do. But every nursing act, as an intervention in the lives of others, has at least the possibility of promoting or transgressing some good or value.
The values dimension of nursing, then, is very complex. It encompasses full-blown ethical dilemmas—situations involving two or more conflicting values or principles such that one can be satisfied or realized only at the expense of not satisfying the other—and much more besides. Many situations raise or present ethical concerns but are not necessarily crises or dilemma situations. Whatever the situation, knowing what one values and being sensitive to the values of others as well as related professional values are essential conditions for responsible and ethical practice.
6.2. Relevant Codes, Policies, and Laws
A knowledge base in ethics for nursing also includes codified ethics—codes, policies, and laws—as they relate to nursing practice. This includes codes of ethics and various guidance documents promulgated by professional associations, and guidance documents and directives issued by regulatory bodies. Nurses should also be familiar with any relevant policies and protocols issued by the institutions in which they practice, and with law to the extent it bears on their practice.
As important as they are, codes, policies, or laws cannot take the place of, or eliminate the need for, ethical decision-making. For one thing, they are bound to be vague or silent about many ethical issues that arise for nurses. Even when they are explicit, the answer that one was simply doing what was mandated by a code, policy, or law is never enough to satisfy the demands of ethical accountability when the moral appropriateness of a particular action is called into question. Ethics is largely about being able to give reasons in defence of what one decides, and this includes even the decision to abide by (or to reject) the injunctions of a given code, policy, or law. Moreover, codified ethics are not absolute or infallible. To take the case of law, an action may be legal, yet unethical from one standpoint or other. Similarly, something that is illegal may be ethically permissible or even required in some values systems. Laws and social norms change over time, as has occurred with MAID . Until recently, a physician or nurse practitioner who assisted a patient to die under any circumstances would have been guilty of a serious criminal offence.
Although ethical codes, policies, and laws do not settle an ethical issue in absolute terms, they do furnish a starting point for reflecting on a given issue. They embody the collective wisdom of our profession, institution, or
community. Although those who bring ethical analysis to bear on an issue may arrive at contrary conclusions, it would be arrogant to do so without having at least considered the codified ethics, policies, and laws on these matters. Moreover, given the authority that stands behind them, the consequences of ignoring or transgressing official edicts can be very grave, and ought to be weighed in the deliberations of a prudent person. On the positive side, codes of ethics, policies, or laws, in addition to providing guidance, can give powerful support and backing for someone working in a setting in which other people are inclined to ignore ethical concerns. Further, such guidance can reduce the uncertainty and/or distress of all health care providers, including nurses.
6.3. Ethical Theories and Fundamental Concepts
There is an entire branch of philosophy devoted to ethical theory, which includes applied and professional ethics. These disciplines bring ethical theories to bear on practical issues arising in the professions. We believe that nurses should have at least some rudimentary knowledge of the main lines of theoretical enquiry in ethics and we therefore have included a primer on ethical theory in this book to provide this background.
At the very least, nurses should have facility in the use of fundamental concepts by means of which to identify, describe, and analyze ethical issues. The six concepts that form the skeletal framework of this book—beneficence, autonomy, truthfulness, confidentiality, justice, and integrity—have been chosen because they are foundational in nursing ethics. Fortunately, most of these concepts are already part of the ordinary language of nursing, and so education in this area is largely a matter of building on or deepening what one already knows. Ethics, after all, applies to everyone, and everyone has the basic equipment necessary to conduct of a moral life.
However, the common-sense usage of moral concepts has many inadequacies. In the first place, these concepts are frequently assigned vague and even contradictory meanings. In moral disagreements people often talk at cross-purposes because they interpret terms and concepts differently. Secondly, moral analysis often comes quickly to a point where two or more positions, each of which expresses a competing value, are at odds. A more philosophical understanding of the fundamental concepts used in moral analysis and the tensions between them can help to sort out confusions, clarify disagreements, and promote creative problem-solving. This is desirable both with respect to the
nurse’s ongoing commitment to self-examination and his or her desire to do what is right.
6.3.1. The Task of Reflection
The three subject areas described above—moral beliefs and values; relevant codes, policies, and laws; main ethical theories and fundamental concepts— constitute a reasonable knowledge base for ethics in nursing. However, acquiring knowledge is not the same as becoming virtuous, except insofar as acquiring knowledge can itself be said to be a virtue. That people are good at the process of values clarification; well-versed in relevant ethical codes, policies, and laws; and well-read in the nursing ethics literature and in moral philosophy, does not mean that they will be good in the sense of acting with virtue. Someone can be well-informed about ethics but insensitive or even cruel. Conversely, someone may be very kind but ill-informed about ethical concepts and moral reasoning. Even so, becoming more reflective in view of the ethical knowledge base that bears on the practice of nursing can facilitate the cultivation of the virtues thought to be desirable for nursing. Such reflection can help nurses to
■ become more sensitive to the ethical dimension of nursing;
■ recognize and identify ethical issues when they arise; and
■ analyze ethical issues more thoroughly (e.g., describe the main arguments that can be deployed on either side of a given issue, bring relevant concepts and principles to bear on options, and so on).
The moral life presents itself to us as a task and a challenge, and the task will vary somewhat depending on one’s life situation. This book is specifically designed for people whose life situation is nursing and who face the special kinds of ethical issues that nurses tend to face. A good part of developing one’s professional identity in nursing involves developing one’s understanding of the profession’s ethical dimension. One of the main goals of this book is to facilitate the development and refinement of such understanding. The moral task for nurses, however, is not simply a matter of knowing but also of doing or even becoming, and whether good comes of this knowledge depends on the subsequent activity of the reader who at this very moment is finishing this sentence.
7. ETHICAL ANALYSIS AND THE NURSING PROCESS
In a field of human interaction where values are as pervasive as in health care, it is virtually inevitable that conflicts of value will arise in a nurse’s practice. In any given situation, the beliefs and values of the nurse, of the profession, of the patient, of the patient’s family or friends, of other health professionals, and of society in general may come into play. Sometimes the values of all concerned, or even the nurse’s own values, will not be congruent, and the nurse will be faced with an ethical conflict or issue.
The nature of ethical life is such that there can be no mechanical formula for resolving issues when they arise. However, familiarity with the values dimension of the situation, any codified statements that may bear on it, and the main concepts of ethics and the ability to bring them to bear on a given issue can be of considerable help. In this regard, a first point to emphasize about ethical analysis—although hardly much of a help to someone in the throes of an ethical issue—is that big problems usually start off as small problems, and often can be prevented or avoided by thoughtful intervention at an early stage. Thus, it is important to become vigilant about proactively raising questions of values in one’s daily practice.
Whatever the nature of the ethical problem, three interrelated components of ethical analysis can be brought to bear: descriptive analysis, conceptual analysis, and normative analysis. Descriptive analysis is directed toward becoming adequately informed about the situation. What is going on in the situation? What are the relevant facts of the matter? What do we know for sure, and what do we need to know to make an informed decision? The task here is to gather whatever information might bear on ethical choice and practice. Such information may include facts about the health status and medical condition of patients, the perspectives of the main agents involved, information about relevant policies and laws, the relationships of power among the stakeholders, and a wide range of other topics.
Conceptual analysis has to do with clarifying the meaning of key concepts relevant to the analysis of a given case or issue. In addition to the fundamental concepts around which this book is organized, numerous other concepts also come into play in ethical issues and arise in discussion and deliberation about them. Sometimes these concepts are vague or ambiguous, such as “quality of life,” “euthanasia,” “equity,” “racism,” “rights,” “professionalism,” and may mean different things to different people. Often, concepts are laden with values and
connotations that may skew analysis of an issue in one direction rather than another. Think of the difference in connotation between the terms “assistance in dying,” “mercy killing,” and “active euthanasia,” each of which may be used to refer to the same act.
The task of conceptual analysis is to sort out the various meanings of key concepts and to unpack terms loaded with values and questionable assumptions. What words seem to be at the fore of whatever issue presents, and what do the different people engaged in the issue mean by these words? How might the words used to describe the issue or relevant facts suggest connotations that skew analysis in one direction or another or sidetrack discussion?
Normative analysis is directed toward deciding what ought to be done, all things considered. It involves sorting out the various moral values, duties, or principles that may bear on the issue and any decision to be made. What values or duties are in tension or conflict, and how should they be weighed relative to one another? Who among those involved in the case ought to participate in making whatever decisions need to be made? What options are available, and, ethically speaking, what counts for and against the various options?
All of the above aspects of ethical analysis are important for making informed and responsible decisions and should be integrated into the nursing process. Indeed, the nursing process itself can be elaborated to furnish a useful framework for ethical analysis, as described below.
7.1. Assessment
One of the most important challenges of ethical analysis is to recognize in the first place that an ethical problem or issue has arisen in a particular situation, or that a problem or issue has an ethical dimension. Not infrequently ethical analysis does not get off the ground because those involved do not see the situation or problem as something that has to do with ethics or values. Reporting on their study of nursing ethics, Storch et al. (2009) indicate that “getting participants to recognize the ethical dimension of a situation” was often the necessary first step. As an example they mention an issue concerning a number of new physicians not willing to wear identity badges; the nurses erroneously dismissed this issue as “not being about ethics” (p. 22). Greater familiarity with ethical concepts and typical issues related to those concepts will help nurses develop a sensitivity to the presence of ethical issues that might otherwise go unnoticed or not be identified as such. Ethical analysis can only begin
when an issue has been identified as ethical, or recognized as having an ethical dimension.
If an issue has been identified as ethical or having an ethical dimension, the first step is to work out a reasonable assessment or interpretation of the issue at hand. The emphasis here is on the word “reasonable,” for it is quite likely that one already has a preconceived interpretation to begin with. That the situation presents itself as an “ethical issue” indicates that at least some rudimentary interpretation has taken place.
One’s initial interpretation of the ethical situation may be vague, incomplete, or even false. Interpretation in matters of value may be extremely complicated and subtle. Certain questions should be asked by way of testing and deepening one’s initial interpretation of the issue. What exactly is the issue? Is it properly an ethical issue? What kind of ethical issue? What ethical concepts does it bring into play? What are the relevant facts and how clearly are they understood? What additional information may be needed in order to form a responsible interpretation of what is going on? What is the context in which the issue has arisen? What guidance or direction about how to address the issue may be provided by the mission statement of the institution, relevant policy statements, one’s professional code of ethics, legal norms, and so on? What values are at stake? Whose values? Who are the significant people involved? In what terms do they interpret the issue? Are you certain that you know how they view things? Do they understand your point of view? What are the main arguments on the different sides of the issue? What are the relationships of power among those involved and in the roles they play? Are people free to express their views, and do they feel free? Or is there perhaps some degree of coercion in the circumstances of the situation?
Such questions must be raised in order to work out a responsible assessment or interpretation. Typically, this includes talking with others and putting questions to them. In the course of working toward an interpretation, one will often find that the issue is based on a misunderstanding or lack of communication.
By way of interpreting the issue, it is also important to be as clear as possible about one’s own values. In some instances, one may learn that one is ambivalent about an issue that has arisen. Of course, it is always better to have thought about and decided upon one’s values prior to being thrown into an issue. In part, the purpose of this book is to facilitate such an enquiry into one’s values in a moment of quiet reflection. Even so, sometimes we only discover what our
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‘Choked is my stream with dead men!’ it cried, ‘and still thou slayest!’
But when Achilles heeded not, in fierce flood the river uprose against him, sweeping the slain before it, and in furious spate seeking to destroy Achilles. But as its waves smote against his shield, Achilles grasped a tall elm, and uprooting it, cast it into the river to dam the torrent. For the moment only was the angry river stayed. In fear did Achilles flee across the plain, but with a mighty roar it pursued him, and caught him.
To the gods then cried Achilles, and to his aid came Athene, and close to the walls of Troy again did Achilles chase the Trojan men.
From the city walls old Priam saw the dreadful things Achilles wrought.
And when, his armour blazing like the brightest stars of the sky, he drew near, and Hector would have gone to meet him, in grief did Priam cry to his dearly-loved son:
‘Hector, beloved son, I pray thee go not alone to meet this man; mightier far than thou is he.’
But all eager for the fight was Hector. Of all the men of Troy he alone still stood unafraid. Then did the mother of Hector beseech him to hold back from what must surely mean death. Yet Hector held not back, but on his shining shield leaned against a tower, awaiting the coming of the great destroyer.
And at last they met, face to face, spear to spear. As a shootingstar in the darkness so flashed the spear of Achilles as he hurled it home to pierce the neck of Hector. Gods and men had deserted Hector, and alone before the walls of Troy he fell and died.
Thus ended the fight.
For twelve days did the Greek host rejoice, and all through the days Hector’s body lay unburied. For at the heels of swift horses had the Greeks dragged him to the ships, while from the battlements his
mother and his wife Andromache watched, wailing in agony, with hearts that broke.
The shadow of death came down upon Hector (page 116)
Then at length went old Priam to the camp of the Greeks. And before Achilles he fell, beseeching him to have mercy and to give him back the body of his son.
So was the heart of Achilles moved, and the body of Hector ransomed; and with wailing of women did the people of Troy
welcome home their hero.
Over him lamented his old mother, for of all her sons was he to her most dear, and over him wept, with burning tears, his wife Andromache.
And to his bier came Helen, and with breaking heart did she sob forth her sorrow.
‘Dearest of my brothers,’ she said, ‘from thee have I heard neither reproach nor evil word. With kind words and gentle heart hast thou ever stood by me. Lost, lost is my one true friend. No more in Troyland is any left to pity me.’
On lofty funeral pyre then laid they the dead Hector, and when the flames had consumed his body his comrades placed his white bones in a golden urn, and over it with great stones did they raise a mighty mound that all might see where he rested.
Yet still was the warfare between Greeks and Trojans not ended.
To Achilles death came in a shaft from the bow of Paris. By a poisoned arrow driven at venture and at dark midnight from the bow of an outcast leper was fair Paris slain. While winter snow lay white on Ida, in Helen’s arms did his life ebb away.
Then came there a day when the Greeks burned their camp and sailed homeward across the grey water.
Behind them they left a mighty horse of wood, and the men of Troy came and drew it into the city as trophy and sign of victory over those who had made it. But inside the horse were hidden many of the bravest warriors of Greece, and at night, when the Trojans feasted, the Greeks came out of their hiding-place and threw open the gates.
And up from the sea came the Greek host, and in fire and in blood fell the city of Troy.
Yet did not Helen perish. Back to his own kingdom by the sea Menelaus took her, to reign, in peace, a queen, she who had brought
grief and death to so many, and to the city of Troy unutterable woe.
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