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.

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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. I can’t … I have no idea. Um … just get some normality back in my life. That would be good, I think.9

To be a nurse like Toni Hoffman, or even to be a part-time aged care nurse faced with euthanasia requests, requires the kind of practical moral courage not required of ordinary academic philosophers or bioethicists. They may limit their discussion of Toni Hoffman’s dilemma to the consideration of arguments for and against abstract moral duties in the situation. They do not have to deal with powerful enemies in their workplace on a daily basis; unfortunately this is true of many nurses practicing in Australian public hospitals today.

5. Nursing as a Profession with Its Own Ethics

There is an argument levelled against nursing ethics as a discipline: if nursing is not a profession, how can nursing ethics be a discipline? Matti Häyry sets out the criteria for true professionals as outlined by, for instance, Ruth Chadwick:

Specialized knowledge Long and intensive academic studies Permanent careers Organization and self-rule within the group As a group, a decisive role in the arrangement of the relevant studies, and in the recruitment of new members to the group A distinctive professional ethos, or morality within the work; and posi- tions of considerable responsibility in communities and societies.10

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Nurses, although acting on the instructions of a doctor, still need specialized knowledge of their own to carry out the orders. Many older persons in the nursing home where I work, for instance, need their medications crushed and mixed in pureed food. The nurse needs to know which drugs can be crushed and which capsules can be opened, and also to know which individuals can swallow whole tablets and which cannot. This is only possible if the nurse un- dertakes a swallowing assessment of the resident. She or he also needs to understand the ethical issues that pertain to the use of chemical restraints, and issues concerning deception and lack of informed consent. She or he also needs an awareness of the complex ethical and legal issues related to caring for people who are no longer competent to make decisions about their own care. It could be claimed that all of the above information is the field of other disci- plines such a pharmacology, applied moral philosophy, or law. Nursing knowledge arises from these, however, in the theories and practice of the ex- pert nurse who can synthesize all of the above information into a coherent whole that benefits the resident. As the example of Toni Hoffman shows, nurses undertake long and intensive academic studies. The same cannot always be said of medical practitioners whose continuing education programs accredited by the Royal Austra- lian College of General Practitioners include movie screenings and a “wealth creation” seminar that teaches GPs about investments, how to maximize their profits and even hide their assets from patients who may try to sue them. In the words of a South Australian GP James Moxham who finds the programs ethically unacceptable:

It’s possible to get all your points by going to drug-company-funded din- ners, and you can fall asleep before the main speaker and you will still get your points.11

Australian general practitioners need to earn 130 continuing education points every three years; the wealth seminar was allocated 30 points and the movie screening six points. Registered nurses in Australia must be in possession of an annual practicing certificate; in order to be given this by a state nursing board they must sign a statutory declaration to say that they are practicing in their profession and adhere to the relevant legislation and ethical codes. Although not all people who train in nursing make it their permanent career, most of my present colleagues are women who have practiced nursing for over 30 years in several countries and numerous settings in community and institutional care. Nurses are members of professional organizations and colleges of nursing. Many of them are also members of the International Council of Nurses, which holds biennial conferences. This year’s conference in Taipei had over 3000 delegates from over 100 countries. The International Centre for Nursing

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Ethics at Surrey University offers ethics courses for nurses from all parts of the world. The Centre gives human rights awards for nurses who have distin- guished themselves in their work.

6. The Future of Nursing Ethics

If nursing ethics is to serve the most vulnerable individuals, who most need those with moral courage to speak on their behalf, then it must include a global, political dimension. For this to become a reality, more and better- educated nurses supported by organizations such as the International Centre for Nursing Ethics and the International Council for Nurses are required to develop and articulate the unique position of nursing in health care in all countries and settings. In small part conference papers and book chapters such as this strive to put nursing ethics on the horizon of bioethics and philosophy as a distinct ethos of a profession with its own morality.

NOTES

1. Michael Parker, “Foreword,” Scratching the Surface of Bioethics, eds. Matti Häyry and Tuija Takala, (Amsterdam: Rodopi) 2003, p. ix. 2. Mairi Levitt, “Better Together? Sociological and Philosophical Perspectives on Bioethics,” Scratching the Surface of Bioethics, pp. 20–21. 3. Douglas Olsen, “When the Patient Causes the Problem: The Effect of Patient Responsibility on the Nurse-Patient Relationship,” Journal of Advanced Nursing, 26 (1997), p. 518. 4. Douglas Olsen, “Provider Choice: Essential to Autonomy of Advertising Gim- mick?” Nursing Ethics, 3:2 (1996), pp. 108–117. 5. Australian Broadcasting Corporation, Australian Story: At Death’s Door— Transcript. Program Transcript Monday, 27th June, 2005. 6. Hedley Thomas, journalist The Courier Mail, in Australian Broadcasting Cor- poration, Australian Story: At Death’s Door—Transcript. Program Transcript Monday, 27th June, 2005. 7. Toni Hoffman in Australian Story: At Death’s Door—Transcript. Program Transcript Monday, 27th June, 2005. 8. Sean Parnell, “Scramble to Plug Dr Death Leaks,” The Weekend Australian In- quirer, July 16–17, 2005, p. 30. 9. Toni Hoffman’s concluding words in Australian Story: At Death’s Door— Transcript. Program Transcript Monday, 27th June, 2005. 10. Matti Häyry, “Do Bioscientists Need Professional Ethics?” Scratching the Surface of Bioethics, eds. Matti Häyry and Tuija Takala, (Amsterdam: Rodopi, 2003), p. 92. 11. Adam Cresswell, “Doctors’ Orders: Learn to Get Rich,” The Weekend Austra- lian, September 10–11, 2005, p. 3.

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