Seven DOES NURSING ETHICS FIT in with PHILOSOPHY AND

Seven DOES NURSING ETHICS FIT IN WITH PHILOSOPHY AND BIOETHICS? Leila Toiviainen 1. Nursing Ethics as a Distinct Discipline The aim of this investigation is to show that nurses play a unique role in health care, and that nursing ethics is therefore a distinct field of study. While nurses must obviously build upon the foundations laid by traditional moral philosophy, nursing ethics as a discipline evolves from it—as does, for example, envi- ronmental ethics—as a distinct field of applied ethics with its own conceptual framework. I have used the collection Scratching the Surface of Bioethics, edited by Matti Häyry and Tuija Takala, as the basis for my investigation into whether nursing ethics fits in with philosophy and bioethics. In that book, the authors emphasize the interdisciplinary nature of the bioethical endeavor; to this I want to add the voice of nursing, since it is silent in their deliberations. I argue that nurses have particular skills not possessed by other health professionals, a fact which much philosophical or bioethical literature fails to recognize. We can trace the origin of these skills to the fact that nurses, unlike any other health professionals, provide round-the-clock care to patients in an almost unlimited variety of settings. The relationships they establish with patients and their families are more intimate and more demanding than the lim- ited engagement typical of other health professionals. The involvement of nurses in the daily activities of dressing, feeding, and toileting patients confers a low status on the emerging profession in the eyes of some academics. How- ever, I regard this intimate involvement in the daily lives of vulnerable individuals as a privilege, and one which confers upon nurses the right to speak for themselves on professional issues. If nurses play an indispensable role in the health and wellbeing of their patients, then their ethics education must equip them for that role, providing them with the skills necessary for it. I explore the alternatives of who should provide them with this education and how it should be done. I do this from the perspective of a bioethics lecturer at the University of Tasmania and of a registered nurse working at a Tasmanian nursing home. Leila Toiviainen - 9789042027404 Downloaded from Brill.com09/28/2021 10:21:07PM via free access 62 LEILA TOIVIAINEN 2. The Ethical Work of Nursing Nurses deal with what Michael Parker terms “the kind of philosophical questions so intimately part of the human condition, like those of birth, death, love, and loss”1 in a way that other health professionals do not. They are present not only momentarily but continuously. In the case of birth, they support families through the antenatal period, labor, delivery, postnatal, and home care. Nurses who work in neonatal intensive care look after premature babies on respirators; often those babies’ lives end after weeks and months of improvements and deteriorations. The parents of these children obviously need ongoing support to prepare them for their loss. At the other end of life, nurses working in nursing homes give residents care over months and years. During this time, they come not only to know the residents well, but also their families, and share in many of their joys and sor- rows, such as the births of great-grandchildren or the loss of sons and daugh- ters on the part of the oldest residents. Seriously ill residents sometimes con- front nurses with euthanasia requests in the absence of doctors, or because the doctors are less approachable than nurses. As euthanasia is illegal in Australia, nurses must find ways of responding to the despair of individuals in place of and on behalf of doctors, while simultaneously acting within their scope of practice and within ethical guidelines. This is not an easy balancing act, but it is one of the unavoidable roles of a registered nurse. In these situations nurses can, for instance, honestly state that they cannot perform acts of euthanasia, but that they can take nursing measures to allay the resident’s anxiety, to assess the level of her physical and mental pain and dis- tress, and to diagnose its causes and relay this information to the medical prac- titioner. First and foremost, nurses are the one permanent, reliable presence and comfort for patients and their families. 3. Nursing Ethics Education, Philosophy, and Bioethics Students in schools of nursing in English speaking countries such as Australia, New Zealand, the United States, and the United Kingdom are taught ethics either by philosophers or nurses, or occasionally by nurse philosophers. If, as I argue, nurses have a special role in the provision of health care, then their education should reflect this. Nursing is a practical profession that demands a solid theoretical foundation on which nurses can base clinical judgements and practical actions that they can stand accountable for in front of the general public, and increasingly in courts of law. Ethics education should ideally do this by fitting theory and practice together into a coherent whole. If this is the case, then those teaching nurses need to know about the realities of their practice, Leila Toiviainen - 9789042027404 Downloaded from Brill.com09/28/2021 10:21:07PM via free access Nursing Ethics, Philosophy, and Bioethics 63 while at the same time having a sound knowledge of moral philosophy and bioethics. The sociologist Mairi Levitt claims that bioethicists do not ask empirical questions that have a direct bearing on everyday health care, for instance about the justification of a liver transplant for an ex-alcoholic who might take up drinking again and waste the donor liver.2 Nurse ethicists certainly ask these questions. Douglas Olsen of Yale University School of Nursing, who previ- ously worked as a community nurse in Alaska, has done empirical research to demonstrate that nurses find it more difficult to act ethically toward patients who in their judgement have caused their own problems, such as smokers, al- coholics, non-compliant diabetics, many AIDS victims, and patients who use violence and intimidation.3 He also touches on economic and social issues, such as patients not being able to exercise freedom in choosing their health care provider, because they lack the knowledge necessary to do so.4 4. Nurses and Practical Moral Courage In Australia we have in Toni Hoffman an example of a registered nurse who can combine ethical theory with nursing practice in a way that has led to legal action against a surgeon and hospital Management. She works in an intensive care unit at the Bundaberg Base Hospital in Queensland, where she reported the incompetent practices of a surgeon, Jayat Patel. Patel’s practices had led to the deaths of several patients. Prior to this appointment she had worked for five years (including the Gulf War period) in Saudi Arabia with “a lot of really brilliant surgeons.”5 At the end of 2002 she completed her Master of Bioethics degree. Dr Patel started at Bundaberg Base Hospital in 2003. It has taken until this year for the matter to attract enough publicity for an investigation to be started into Dr. Patel’s malpractice, and into the deaths of several of his patients. Although one of the anesthetists had called Dr. Patel “Dr. Death,” and had maintained that he would not want to be operated on by such a surgeon, and despite Dr Patel’s colleagues being aware of his incompetence, he was not stopped from harming his patients. As a journalist reports, “There were doctors aware of what was going on, but they didn’t respond as forcefully as the nurses, and in particular, Toni Hoffman.”6 The senior nurses in administration did not take her complaint seriously, but the Director of Nursing, Linda Mulli- gan “gave me a book to read on how to deal with difficult people. It wasn’t that we were dealing with clinical incompetence and we needed someone to pay attention and listen.”7 Although the case of Toni Hoffman as a whistle-blower on a surgeon who made numerous fatal mistakes is fortunately extreme, it highlights my argument that nursing ethics plays a role that is not only subsidiary to philosophy or bioethics, but extends to the very foundations of clinical practice. While Leila Toiviainen - 9789042027404 Downloaded from Brill.com09/28/2021 10:21:07PM via free access 64 LEILA TOIVIAINEN nurses must understand the basics of deontology, it is hard to imagine that Kant could have provided Toni with adequate guidelines on how to act in this situation. And yet, Kant would have advised her to speak the truth without considering the consequences to herself, because of her duty to her patients. He would have failed, however, to appreciate the emotionally draining effects on Toni of dealing with distressed patients and relatives, and of her being bullied by the hospital Management and later the courts. She was, for instance, criticized failing to bring the matter to the attention of Management earlier.8 Toni Hoffman has been left to deal with the consequences of her truth telling. Her duty to her patients is fulfilled, but her life and career are on hold: I mean, we’ve been bullied and intimidated for so long now that I have no idea what the future holds. I probably have made some enemies because of this, but I did have to be a patient advocate. I think that I’ll just keep going to work and I’ll probably have some time off at the end of the year and go overseas and, I don’t know, I don’t know.

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