The ethical enterprise of nursing

foumal of Advanced Nursing, 1992,17,16-20 The ethical enterprise of nursing Peter Allmark RGN BA(Hons) Staff Nurse, Coronary Care Umt, Royal Hallamshtre Hospital, Sheffield, England Accepted for pubbcation 17 June 1991 ALLMARK P (1992) Joumal of Advanced Nursing 17,16-20 The ethical enterprise of nursing This paper examines the ethical nature of nursing Examples are taken from coronary care umts A cntical view is taken whereby it is felt that nursing models do not truly reflect this nature It is suggested that nurses make most ethical decisions without dilemma usmg lntiuhon The tradihons behind usmg this mtuition are exammed Such normative traditions may be summarized as teleological, deontological and axiological Lastly, it is suggested that nurses would benefrt m several ways from some education m ethics INTRODUCTION- APPROACHING ETHICS IN NURSING rmght add that nurses who ignore philosophical ideas on ethics are doomed to repeat nustakes of the past The If my mmd could gam a foothold, I would not wnte essays, I attempt to provide ethical 'ready reckoners' is an example would make deosions, but it is always m apprenticeship and of such a mistake The assumption behmd them is that assessment of empincal data can lead to ethical judgement, on tnal (Montaigne 1970) that 'ought' can be denved from 'is' Philosophers largely now beheve this to be false (Hare, ated m Magee 1978, There have been two main approaches to the apphcahon of Barrett 1987) The approach here is slightly dififerent, although it bears ethics m nursu^ These have started from the premise that etbcs is about solvmg dilemmas on major issues most relahon to the first method The impbcahon of both such as euthenasia, aborhon, lymg, 'shoppmg' miscreant the above approaches is that nursmg is a prachcal entercolleagues, and so on From this premise, one approach pnse which occasionally meets ethical problems The has been to examme the dififerent normahve philosophieal author shaU argue that nursmg is, of its nature, an ethical theones (e g Benjamm & Curtis 1986) These have then enterpnse Nurses are makmg ethical deasions much of the been applied to the vanous ethical dilemmas m order to time, although these are not always perceived as ethical lUustrate dififerent p>ossible approaches a nurse nught take unless a sense of dilemma is felt The queshon thus anses, The more common approach (Craig 1989, Dimaway 1988, how do nurses actually make such deasions? In order to Roche 1987) has been largely to ignore any insights philos- answer this, the ethical assumptions of nursing models are ophy may ofiFer Instead, a systematic approach is pre- exammed This is followed by a study of theones of ethical sented, often based on a revamped form of the nursmg deasion makmg (normahve ethics) and of the status of process, assess, judge, plan, implement, evaluate ethical statements (meta-ethics) The second approach is temptmg It offers a pradical guide to dilemmas, and it avoids delvmg mto the obscure realms of philosophical theory Such delvmg may be seen Examples from a coronary care unit as pointless because nurses are not familiar with it, nor are they likely to become so This behef is mistaken Santayana The followmg are examples of ethical deasion making (ated m Maantyre 1968) has said that he who is ignorant situahons m a coronary care umt (CCU) of the history of philosophy is doomed to repeat it One 1 A pahent receivmg mtravenous lignoeame after carCorrespondence Mr P AOmmi. SS Murray Road SieffieU Sll 7GG, Boland diac arrest becomes confused and wants to leave 16 Ethtcs m nursing 2 3 4 5 6 7 8 The nurse deades to prevent this with a mixture of persuasion and physical foree, sueh as eotsides The nursmg offiee phones and asks for a staff nurse to help elsewhere The nurse feels this would eompromise the eare of patients on the umt A man is dying m eardiogeme shoek His wife is by his side She has asked emphatieally that her husband should not be told his prognosis as 'Hope is all we have left' When she leaves the room the man askes, 'Am I dying?' A doetor wants to admit a previously healthy 80year-old onto the umt It is the last bed and no other patient is fit to leave The nurse deeides to oppose the admission A patient is dedared 'not for resuscitation' The relahves are not mformed of the deeision, and the nurse suspeets they would disagree The man arrests The nurse asks the relatives to wait outside and takes the erash trolley to the bedside She takes the man's hand but takes no further aetion She hopes the relatives will believe otherwise A nurse looking after two patients finds she is foeusing her attenhon on a very physieally ill man Her other patient is a relatively well, young lnfaret survivor He is desperately anxious and m need of eounsellmg He does not reeeive it A nurse is unhappy that the pahent m his eare is to be entered into a researeh tnal He knows there is no direet benefit to the pahent, and that it will be tinng and distressmg He feels the patient is well informed of this, but feels unduly obliged to the hospital The medieal staff are applying a seonng system to pahents entermg the CCU It is used to deeide if someone should reeeive treatment, or should be left as they are monbund A man just fails to make the seore neeessary for aetive treatment and is for 'nursing eare only' The nurse is unhappy with this, partieularly as the seore eontains a quality of life element The patient, a tramp, seored very low on this element These situations are of varying types They are all ethieal as they mvolve the question, what ought the nurse do? However, some elearly revolve around issues of resourees, others around reaetions and mter-reaetions of patients, relatives and staff This may be danfied by askmg, what makes nursing ethieal? THE ETHICAL ENTERPRISE Nursmg is an ethieal enterpnse beeause it involves ehoosmg altemahve achons m the treatment of human beings These decisions are nwde m an environment with two erueial limitations 1 2 Limited resourees, sueh that the giving of somethmg, like nursmg time, to one pahent will involve withholding from another Limited knowledge, sueh that we do not know how a patient will reaet physically and spiritually to a nursing action The man told he is going to die may be able to find some peace, or may enter paroxysms of despair The environment of limitations m whieh nursmg takes plaee ensures that many nursmg aetions have an element of uneertamty about them Nursing takes plaee amidst doubt about deeisions affeetmg other people, the very stuff of ethies We are enhtled to ask how nursing takes plaee Nursing models It IS a shibboleth that nurses use the nursing proeess as a systemahe approaeh to nursing care, and nursing models as a basis for applieation of the proeess It is eertamly true that those praehsing individualized patient eare probably also apply some form of systemahzed approaeh whieh may be ealled 'nursmg proeess' Some nurses also make a eonseious effort to use nursmg models What are the ethieal lmpheations of these models? A model ean be defined as either desenphve or presenphve In desenphve terms, it is the simplified representation of an existant, sueh as maps, models of the weather or eeonomy, and so on In presenphve terms, it is the simplified representation of a proposed stmeture, sueh as a prototype of a bndge or a ear The often-quoted analogy of a nursmg model with a map is a false one, as nursmg models are both desenptive and presenptive In general, they eontam a descnphve model of an mdividual, of man, and a presenptive model of how sueh an individual should be nursed In other words, a nursmg model is two models The most eommonly used nursmg models, Henderson (1966), Roper-Logan-Tiemey (1985) and Orem (1980) have a desenphve model of the mdividual as needs based These needs are seen altemahvely as a hierarehy (along the hnes of Maslow 1970), aetivities of daily hvmg, or self-eare requisites These slightly diffenng desenptive models lead to slightly diffenng presenptive models Fundamentally, nursing is viewed as fulfilling the pahent's needs when he is unable to meet them Nurses themselves are not modelled as separate from their role, there is a perfeet balanee of egoishe pahent and altruistie nurse The deasions a nurse makes beeome obvious, they are those that fiJfil the patient's needs The real ethieal nature of nursmg is not 17 P Allmark revealed because the environmental limits of knowledge and resources are not mcluded m the model Rather than the analogy with maps, nursmg models may be better compared with fashion models These provide an image of how you will look in certam dothes, and then furnish you with a feelmg of inadequacy when you fail to meet the image Nurses attemptmg to apply nursmg models frequently descnbe guilt They have not fulfilled the plan, not met the patient's needs This is because models lgnormg environmental hmitations will suggest 'ought' actions which eannot be met Yet one eannot suggest someone ought to do something of which they are mcapable This is a senous fault, and denves from a failure to examme the environment m which nursing takes place, and a failure to model the nurse as an individual, separate from the act of nursmg Some nursmg models take some account of the environment, such as Neuman's or Orlando's (see George 1990), but not of its limitations The conclusion must be that nursmg models ofifer little giudance m the deasions which largely conshtute nursmg practice Nursing takes place m spite, not because of such models ETHICS Objechvity and humanity carmot co-exist more than a little (Newman 1983) view moral concepts as conshtuhng a kmd of knowledge Non-cogmhvists are usually empincists and believe knowledge is of two types empincal, that which is gathered from our senses, and analyhcal or a pnon, such as the necessanly true knowledge of human ccmstruds like logic and mathemahcs Knowledge of what is good or nght is m neither category and is therefore not knowledge Some versions, such as Ayer's (ated m Maantyre 1968), see ethical predicates as expressions of approval or disapproval Others, such as Hare's (1964), say they express commands Cogmhvists may also be divided Some believe that moral concepts are definable m terms of natural phenomena Most, however, are mtuitiomst and believe moral concepts descnbe entirely unique entities that are known to be true They form a third type of knowledge which may be teimed synthetic a pnon such as purported by Moore (1966) and Kant (Raphael 1990) All cogmtivists would hold that ethics deals with concepts of absolute truth Normative ethical theories Normahve ethical theones are concemed with how a person judges what is nght or good, or what ought to be done They may be sub-divided mto teleological, axiological and deontological Teleological theones We are thus lead to ask how nurses actually make their deasions The pnmary answer is that they use mtuihon, they do what they bebeve is nght or good In some of the above examples, mtiuhon would provide mstant answers for many nurses, other examples would provoke dilemma Two mam questions anse Teleological theones state that moral deasions should be made on the basis of their ends, the results of their implementation The most well known of these theones is utilitcuiamsm This states that we should judge an achon by its utility, by which is usually meant its ability to produce happiness One should choose actions most liable to produce the greatest happmess Utihtananism is often apphed 1 What IS the nature of our knowledge of nght or good? m the health service, mdeed it is said the health service is This may be called the rejJm of meta-ethics based on this pnnaple The formulas for the allocation of 2 How do we judge when an adion is nght or good? resources m the service, such as quahty adjusted hfe yeare How do we deade what we ought to do? This may be (QALYs), are dearly utihtanan The nursing process called the recilm of normahve ethics implies a teleological, if not uhlitanan approach It IS m the latter area that nurses' mterest would pnmanly There are problems with such an approach First, adoptbe focused However, the distmchon is a slightly artifiaal mg it can lead one to take achon that is dearly unethic£il one Up unhl this century, most ethical theones would One example (adapted from Hare m Magee 1978) is if there have a normative and meta-ethical comjwnent, and these are two pteople m a hospital needing transplants, one a would be closely entwmed bver, the other a heart, to save their lives Meanwhile, other patients need kidneys and rehnae m order to improve thenlife quality If a healthy person of suitably compatible tissue Meta-ethical theories walked mto the hospital, the ethical thmg to do would be to Meta-ethical theones are concenwd with the status of ethi- kill him and donate his organs cal knowledge {Encyclofoedia Bnttamca 1985) They can be Utilitanans have answered this cnhasm by creatmg divided mto cogmhvist and non-cogmhvist Cogmhvists rule utibtanamsm This states that our achons should be 18 Ethtcs tn nurstng govemed by pnnciples of overaU utdity Murder is wrong because it nearly always produces less bappmess, hence it is wrong even wben it produces more happiness A second cnhcism is that utditanamsm is impractical We bave already argued tbat in nursmg we are constantly making etbical deasions Clearly, we do not go tbough a process of reckomng up utdihes eacb time we decide Even if we did, predictmg end results is rarely possible Wbat Sartre (Kaufmann 1975) called tbe prachco-inert, tbe world onto wbich we put our ideas into prachce, robs us of our exf)eeted results Nonetbeless, wblst uhbty may not be good as tbe sole entenon for etbeal deeisions, it is at the root of some of them For example, tbe nurse above, faeed with a eonfused patient, wdl a d against his will, and b s nghts, for b s greater long-term happiness Axtological theones Axiologieal tbeones say that moral deasions sbould be made on tbe basis of the act itself Van Hooft (1990) advocates sueb an approaeb for nurses Aets bave an lnberent morality Tbere are several different approaehes here, from agapeists to existentialists Agapeists (Thompson 1988) view the eapaeity to love as man's essential nature Moral judgements are made by deeidmg wbat is the most lovmg tbng to do in the circumstances Existentialists stress the particular and individual nature of eacb person and eacb situation We are eacb constantly faced with diverse possibilities from which we must choose, and to which we must commit ourselves Wbat we deade is our decision, someone else may bave decided differently Sartre (Kaufinan 1975) stressed tbe lrreducibdity of existence to reason, man is faced witb choices which are infimte and equivalent Axiologieal tbeones tend to imply situahon etbes Eaeb situahon is unique, and eaeb individual must deeide m tbe situation Attempts to apply rules or duties to situations are viewed as bad faith, Deontological theones Deontologieal tbeones say tbat moral deeisions sbould be made on tbe basis of duty Offieial moral eodes refleet such a posihon The best known deontologist was Kant We earlier descnbed Kant as being, m meta-etbcal terms, an inhiihomst cogmtivist He bebeved tbere are etbcal predicates tbat are known to be tme Tbese he called tbe categoncal imperative, of wbcb tbere are t b e e aspeds (summanzed m Raphael 1990) Universalize your adions, you should a d m a way tbat you would want anyone to act in the situahon 2 3 Treat buman tjeings as ends and not means Act as a memt)er of a commumty of ends, of buman bemgs who are moral bemgs bke yourself Tbs asped emphasizes each individual's necessary freedom Tbe case of a pahent bemg entered mto a medical tnal (see above) is illuminating A utditanan would tend to aUow tbe tnal on the basis of overaU utibty A Kantian would disaUow it as treahng a person as a means and not an end However, the very fact tbat it is possible to disagree over such a case lUustrates tbat tbe categoncal imperative is not a pnon knowledge DISCUSSION Moral concepts change as social hfe changes (Maantyre 1968) Tbs study bas been discussmg etbcal tbeones as tbougb tbey were purely produced by mteUectual discussion In fact, tbey were produced at different times, and reflected tbe soaety in wbch tbey were produced Kant's categoncal imperahve appeals to us t)ecause it is an etbcs of an aspmng democrahc society Utditanamsm dearly reflects tbe economic tbeones of capitabsm Existenhabsm was formulated in an era of world wars, and a pletbora of causes As mdividuals, we unconsaously lnbent tbese many different traditions of morabty When we act mtuitively we reflect tbese traditions T b s becomes obvious wben we consider tbe reasons for our achons At times we may invoke utditanamsm to justify, for example, domg sometbmg to someone against tbeir wiU At otber times we sball use deontological arguments to prevent a patient entenng a medical tnal Most of tbe time, nurses making moral deasions do so witbout any great feelings of intemal conflict Dilemmas occur when faced with a deasion from which two or more of our inherited traditions imply conflichng answers, or occasionally wbere one tradition implies a conflictmg answer Existentialism correctly identifies that we must cboose But the concepts we employ in makmg sucb a choice reflect the society in wbcb we bve, and tbe bstory of its ideas CONCLUSIONS Do unto others as you would have them do to you (Luke 6 31, Oxford NN Scofield Study Btble 1984) Tbere are two major condusions tbat may be drawn First, we bave suggested tbat nurses are constantly makmg 19 P Allmark deasions of an ethical nature Nursmg models fail to reflect the ethical nature of nursing for at least two reasons Dunaway P (1988) Deasions to discontmue mtensive therapy Intenstve Care Nurstng 4(3), 106-111 Encycbpaedia Bnttanica 15th edn (1985) Encydopaedia Bnttanica 1 They do not reflect the environment of lmuted International, Walbngton, Surrey knowledge and resources m which nursmg takes place George IB (1990) Nurstng Theones Prentice HaU, London 2 They fail to view the nurse as an individual separate Hare R M (1964) The Language of Morals Clarendon Press, from his or her role Oxford Henderson V (1966) The Nahtre of Nursing A Definihon and tts The use of nursing models will suggest actions she/he Imphcahons, Prachce, Research and Edttcahon MacmiUan, New cannot do, and goals she/he cannot meet York Second, the study has also exammed the way in which Kaufmarm W (ed) (1975) Extstenttaltsm from Dostoevsky to Sartre nurses actually make deasions, and the tradihons they Mendian, New York inhent and reflect The second condusion is that nurses Macmtyre A (1968) A Short Htstory of Ethtcs MacmiUan, London would benefit from educahon in ethics Three reasons MageeB {ed)(197S) Men of Ideas BBC, London suggest themselves Maslow A (1970) Mohvahon and Personality Harper and Row, 1 It would enable nurses to view cntically the easy New York solutions proferred for moral dilemmas These lnvan- Montaigne M (1970) Essays (transl Cohen J M ) , Penguin, Harmondsworth ably reflect only one tradition, usually utibtanamsm Nurses should be able to present altemahves m their Moore GE (1966) Pnrtapa Ethica Oxford Uruversity Press, Oxford role as advocates Newman G F (1983) The Nahon's Health Granada, St Albans, 2 Nurses could identify the processes by which they make Hertfordshire deasions Orem D (1980) Concepts of Practtce McGraw HiU, New York. 3 Nurses would be empowered to see that their opinion Oxford NIV Scofield Shtdy Btble (1984) Oxford University Press, matters If they believe somethmg to be wrong, it Oxford cannot be wholly nght Raphael D D (1990) Moral Phtlosophy Oxford University Press, Oxford Roche E (1987) Ethical deasions in nursmg The Professtonal References Nurse 2(6), 164-166 Barrett W (1987) Death of the Soul Oxford University Press, Roper N , Logan W & Tiemey A (1985) The Elements of Nurstng Oxford ChurchiU Livingstone, Edinburgh Benjamin M & Curtis J (1986) Ethtcs tn Nurstng Heinemann, Thompson I (1988) Nursmg Ethtcs ChurchiU Livingstone, London London Craig R (1989) The nurse's role in ethical decisions Nurstng van Hooft S (1990) Moral education for nursmg deasions 3(36), 42-43 Joumal of Advanced Nurstng 15(2), 210-215 20