The Task of Nursing Ethics

of medical ethics 1994; 20: 7-11 J7ournal J Med Ethics: first published as 10.1136/jme.20.1.7 on 1 March 1994. Downloaded from The task of nursing ethics Kath M Melia University ofEdinburgh Author's abstract I shall argue that nursing has a particular This paper raises the questions: 'What do we expect contribution to make to the ethics and health care from nursing ethics?' and 'Is the literature ofnursing debate, but that the contribution need not ethics any differentfrom that of medical ethics?' It is necessarily be the production of nursing ethics suggested that rather than develop nursing ethics as a in contradistinction to medical ethics or bioethics. separate field writers in nursing ethics should take a lead Rather, nursing could take advantage of the fact that in making the patient the centralfocus of health care its work requires a particularly close and continuing ethics. The case is made for empirical work in health contact with patients and so contribute to the care ethics and it is suggested that a good way ofsetting ethical debates a consideration of the patient's about this is to ask practising nurses about the real perspective. Instead of discussing autonomy, rights, ethical problems they encounter. beneficence etc nursing could start at the patient experience and ask what in the context of their copyright. condition, be it stroke, amputation, AIDS or There is a lack of empirical work in the literature whatever, does it mean to take care of a patient and concerned with nursing ethics. It is my contention give consideration to his or her autonomy, rights that this gap has left the way open for the and freedom. Nursing's contribution, therefore, development of a particular kind of writing, a rather would not to be to create nursing ethics but to inject prescriptive Olympian style of handed down ethics. health care ethics with a more patient/client-led This trend has led to a focus on particular perspective. In order to do this the field stands in http://jme.bmj.com/ philosophers and this in turn has helped to shape the need of empirical work and some consideration of area of applied ethics that has come to be known as two questions, first, what currently counts as nursing ethics. These issues are at the heart of the nursing ethics and second, what it is that we expect question: 'What should nursing ethics look like?' of nursing ethics? What, in other words, is the task Nursing ethics is a difficult area of study to of nursing ethics? apprehend, especially if it is to be considered as an Over the last decade a considerable body of entity in its own right, that is, in some way separate literature has built up in the area of nursing ethics. on September 26, 2021 by guest. Protected from medical ethics or bioethics. Nursing has a Some of the first writings on nursing ethics appeared particular relationship with medicine within the in the United States literature at the turn of the organisational structure of health care and, indeed, century, with a considerable amount being written in the hierarchy of occupations. In so far as any in the first twenty years or so. There was not a lot occupation can claim autonomous professional written on the subject in the 1940s and 1950s, but status and operate within a bureaucracy, medicine there was a steady rise from the 1970s to the present has managed to lay claim to and maintain day. Speculations on ethical questions are becoming professional status, in that it has control of its work increasingly popular, both in the general and the and membership. Nursing work is dependent in part nursing press. on medical practice and so the occupation can at It might be argued that the efforts that nursing is best only lay claim to semi-professional status. This making in an attempt to achieve professional status dependence on medicine means that nursing, when could have something to do with the increasing it wishes to develop itself, has a tendency to want to interest in ethics. The production of nursing ethics pull away and engage in uniquely nursing activities texts could be seen as no more than a consequence and debates. of a growing number of academic departments of nursing. Whatever the aetiology, it remains the case that nurses are now plainly interested in the ethical Key words dimension of health care. Nursing ethics exists as a phenomenon with a life of its own and it is unlikely Nursing ethics; care; health care ethics; research. to go away. 8 The task ofnursing ethics J Med Ethics: first published as 10.1136/jme.20.1.7 on 1 March 1994. Downloaded from As a contributor (1) to the nursing ethics doctors exercising these powers. One only has to take literature, for me to suggest that nursing ethics has a look at other areas of psychiatric care (3) to see that no right to an independent existence or that the nurses have a lot to do to put their own house in motivation for ethical debate within nursing is not all order, before invading medical territory. that it should be is perhaps disingenuous. However, This rather military-style language draws attention the time has come when questions have to be asked to the fact that much of what we are dealing with in about the nature and purpose of nursing ethics. ethical debates in nursing and in health care generally I have changed my perspective on nursing ethics is professional territoriality and power. Nursing's over the last few years. After ten years of working in position in relation to medicine is, then, to a large the field of bioethics, first on research projects extent determined by power. Issues of power and involving a multidisciplinary research approach to control essentially define the domain of the concerns bioethics and latterly writing about nursing ethics, I of nurses and this includes ethical concerns. Doctors am still not altogether sure that we need a thing may take the decision to discontinue care - nurses called 'nursing ethics', as opposed to a more have to put that decision into practice. Doctors, for generalised 'health care ethics' (2). Why should we instance, may admit a patient on a voluntary basis, it consider nursing ethics as an area of concern which is is the nurse that has to 'keep' the patient in the ward. independent of medicine? Would an adequate notion Nursing ethics has, then, so the argument goes, a of nursing ethics not simply be a reflection ofmedical claim to an existence that is separate from and ethics? The general argument that is put forward for independent of, medical ethics. I know this argument the existence of nursing ethics is that the occasions well and have made it as a justification for writing giving rise to ethical concern are often the same for about nursing ethics (4). However, before nursing nursing as for medicine - abortion, euthanasia, care ethics gets to be very much older, I think we should of the mentally ill, reproductive technology, intensive take a close look at this justification and the product care, prolongation of life - but the difference for that it allows, namely nursing ethics. ethical debate lies in the way the issues present and Lest this paper appears to be rather too damning, the nature of the practical problems they bring. I should make it clear that I do think nurses must The medical profession is often deemed to have take ethics seriously and debate the issues - it is thecopyright. the last word in ethical decisions, albeit in the guise nature of that enterprise and its rhetoric that I am of clinical judgement, because it is ultimately legally questioning. responsible for the patient's welfare. This is a fact that nurses sometimes refuse to accept, or so it would seem in some of the debates about the Who is responsible for what? independent practice of nursing. If, however, we We must look behind the rhetoric if we are to http://jme.bmj.com/ concern ourselves with the situation that currently determine just what it is that nursing ethics might be prevails we have to conclude that the patient has a about - the task ofnursing ethics. It seems to me that contract, both legal and moral with the doctor, not the nursing ethics literature is by and large no more with the nurse. Some of the most notable cases than a mirror image of the medical or bioethics where nurses have challenged doctors on moral literature. It tends to discuss the same issues, grounds have been fundamentally flawed because dilemmas and philosophers. There may be a good nurses were making challenges from a weak position. reason for this. It could be that to sustain the notion This is true in the cases where student nurses, often of nursing ethics as a separate entity is easier said on September 26, 2021 by guest. Protected with the backing of qualified staff, have refused to than done and so one would not expect to find much take part in electro-convulsive therapy (ECT) difference between the nursing and medical ethics sessions or refused to administer drugs because they texts. It is perhaps the interplay between the two believed it was not in the best interests of the perspectives on ethical issues - medicine's and patients. It would seem to me that unless a nursing's - that has been neglected. psychiatrist is prescribing and administering ECT in Much of the nursing contribution to ethical a way that is not compatible with the code ofpractice debates centres around the idea of doctors' values of the College of Psychiatry, then the nurse has no being hidden in clinical decisions and dressed up as grounds for complaint and non co-operation.

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