Modern science and technology not only present a challenge to
contemporary religious faith but also in a much more subtle and
pervasive fashion they threaten to undermine the basic values often
associated with religious beliefs and practices. The crises in values is
witnessed in the myriad of contemporary ethical issues and the growing
awareness that society is not doing enough to prepare its members,
especially its professionals, technicians, and business and political
leaders to handle situations that pose moral problems. This article
deals in particular with what is known as nursing ethics; however, the
more general remarks are applicable to other fields as well.
Consider the following situation. The development of prenatal testing
of fetuses (amniocentesis) which supplies knowledge concerning a number
of abnormal fetal conditions coupled with the development of abortion
procedures that hold low risk for the mother present women, and in some
cases men, with the decision of whether or not to terminate the
pregnancy "because" of the presence of an actual or merely a possible
(especially in the case of sex-linked recessive genetic diseases)
abnormal fetus. There are some who do not see the moral problems
involved even in the case of the merely possibly abnormal fetus. The
acceptance of the scientific, supposedly objective, or even merely
statistical designation of abnormality appears for some at least to
settle the issue. "Abnormal" is equated with "unacceptable" and to be
avoided, even perhaps, at all costs.
Some are not sensitive to or do not appreciate the ethical issues
involved. The value of human life, even an "abnormal" human life,
appears to be displaced by another "higher" value or removed from
consideration by some thought process that does not explicitly involve
ethical considerations.
However, this situation presents a moral dilemma for the pregnant
woman that did not exist before the availability of scientific-technical
procedures. The woman must answer the many questions involved and they
are to be answered at a time that highly values scientific productions
and technical progress. The concerns and pressures on the woman are
great and include, among others, society's desire to avoid another
burden (care of abnormal children), especially if it is an "unnecessary"
burden, which is equated with "avoidable."
As difficult as this situation may be to the pregnant woman involved,
consider the nurse who attends the woman or who is asked to participate
in or to administer the abortion procedure. The nurse's dilemma is often
overlooked. It is taken for granted that the nurse will look after the
welfare of the woman. The nurse is seen by some nurse- advocates as a
patient-advocate who serves the needs of the patients. But just what are
the proper limits to the nurse's concern? Is the nurse responsible for
the physical welfare? The social? Economic? Spiritual? The nurse's role
is defined in response to the answers to these questions. To the degree
‘that the nurse's responsibility is limited to the physical sphere, the
nurse comes under the medical model of care. Is the woman pregnant with
an abnormal fetus a patient? Is she sick? What is the illness, the
disease? With only physical criteria to work with there is an
abnormality and intervention is the generally accepted, even
necessitated, response.
In a similar way several other situations confronted by nurses can be
viewed. Take for example the existence and use of life support machinery
and chemicals and the question of whether or not to continue to preserve
life of certain limited life processes. Human dignity, the right of
self-determination, privacy, and the value of life itself are issues in
such cases involving what is commonly mislabeled as the "right to die".
In such situations, the nurse as well as the suffering person is
involved with these issues: the patient-person directly and the nurse
directly as one duty bound to respect the rights of others and the
indirectly as the patient's advocate-protector.
Beyond such situations there are those which pose moral problems in a
unique way to the nurse, as a nurse, and do not involve the
person-client-patient in the same way. The nurse must decide whether to
follow the physicians’ orders or not when the physician asks the nurse
not to inform a competent person of the nature of the illness or to
reaffirm a false diagnosis, or when the physician prescribes an
excessive and potentially harmful amount of a medication. What is the
nurse to do when threatened with the loss of position for refusal to
follow the physician's instructions? What is the nurse to do while
witnessing a physician or fellow nurse about to perform a harmful act
upon a patient, whether out of ignorance, accident or misintention? Must
the nurse always prevent harm? Must the nurse physically restrain the
physician? Must the nurse report such incidents? What of the
consequences to the nurse? To the patient? What are nurses to do who
witness the systematic harming or jeopardizing of the
physical welfare of their clients (patients) by the health care
facility? Must they stand by, politely protest, or actively intervene,
even strike?
These later situations present problems unique to health
practitioners, especially nurses, and they call into question what the
nurse's role is within the medical institution and society. They call
into question or place the values of individuals over against that of
social institutions and individual rights and duties over against social
roles.
The debate within the field of nursing and within the health care
institution as to what the proper role of the nurse is or should be
exacerbated by those who advocate that the nurse's professional concerns
expand beyond the physical welfare of the patient. Such as expansion
would present new sets of problems. If, for example, nurses are given
responsibility for the social welfare of their clients, then their
position within the social health care institution will become
considerably altered. Will they then be able to advocate for their
clients against the interests of the society which trains, licenses, and
supports them or will they become part of the socialization process
themselves? Is "Let's take our medicine" to be replaced by "Let's not
burden our other children or our state"?
If nurses are, for example, to consider the economic welfare of their
clients before they advise or take action, then there would be
considerable political pressure within the medical institution whose
continued existence in its present form depends upon economic factors.
Physicians and hospital and nursing home administrators are not likely
to accept such an expansion of the nurse's responsibility that might
threaten to alter the very nature of the institution let alone the
relative economic and political status of the various health
practitioners.
If nurses are to consider the spiritual welfare of the human being
the nurse cares for, perhaps the greatest threat is posed to the
established institutions which train and expect nurses to function as a
nurse only, to remain within the socially defined role, and in some way
to separate themselves from, their greater role as human beings. How is
it possible to have a human being surrender human rights, prescient for
accepting the responsibilities one human being has toward another, and
disavow basic duties as human beings? It happens in an advanced
technological society that views individuals as their social roles
define them and trains them as technicians to handle problems only in
institutional settings. Consider that the questions in this case
vis-à-vis the nurse have been posed with reference to the nurse as a
nurse and not first as a human being. Astonishing as this may be to
some, it is common to find in the public discussion a virtual denial of
the basic human rights and duties of nurses.
How is it possible to have a human being surrender human rights,
reject the acceptance of the responsibilities one human being has toward
another, and disavow basic duties as human beings?
It is only recently that there has come the grudging acknowledgment
that patients have rights but they are recognized in the "Patients Bill
of Rights" as patients’ rights rather than basic human rights as applied
to the medical situation. This document weakly and partially restores
person-patient what had been illegally and immorally denied and usurped.
The call for a nurse's "bill of rights" would equally overlook the
existence of a more fundamental set of human rights and duties that
nurses have as persons and that cannot be denied or suspended in the
medical setting without the sort of consequences now in evidence in the
discussion of the role of nurses, in the moral dilemmas faced by nurses,
and the growing disaffection of large numbers of nurses with their
profession.
The judgment often arises that the way things are not the way things
should be. Often and especially in a democratic and technocratic
society, there is a confusion in thinking that the way things are
supposed to be is what the law provides for. In practice, many people,
and especially technicians and professionals, do not acknowledge that
what is legal is not always moral and what moral is not always legal. It
may be legal to have an abortion but immoral, at least for some. It may
be legal for a nurse not to interfere with a physician causing harm to
someone, but immoral. It may be moral duty to help another understand as
best possible the contingencies in a situation in order to make a
responsible decision as to their welfare and for those for whom they are
responsible. Yet the nurse may be reprimanded or dismissed for doing so.
Most moral issues confronted by professionals and technicians, by
physicians and nurses, are not dealt with ethically at all, i.e.; with a
deliberative reasoning process and explicit, ethical principles.
Instead, moral problems are responded to reflexively with a simplistic
self-defensive posture with self-interest as the primary value or
routinely with a simplistic repetition of traditional procedures.
Employing the stage theory of moral development of John Dewey or
Lawrence Kohlberg most treatments of moral issues are at the
pre-conventional stage characterized by self-interest,
self-gratification, concern for rewards and punishment and reciprocity
or at the conventional stage characterized by the desire to conform to
the wishes of the group accepting its mores and customs as laws and
wishing to uphold the order of the status quo. There is little evidence
of post-conventional ethical thought amongst technicians, business
executives, and professionals such as physicians and nurses in which an
autonomous morality is adopted and in which the individual develops
their own personal principles, develops a conscience and refers to
higher order concerns for social and legal obligations and for human
dignity.
The ways in which professional engage ion dealing with moral problems
is influenced by the social environment which offers models for their
behavior based upon sets of governing ideals, conceptual frameworks, and
well-refined roles. According to one ethician, William, May there are at
least three such models: code, contract, and covenant.
Individuals might respond to a moral problem by referring to a
professional code of conduct. Such codes are often vague, seldom
formally explained, mainly rules of etiquette and intended to have
practitioners avoid legal difficulties and conflicts with colleagues.
The codes usually make only the most general references to humanitarian
interests and goals and in practice make such concerns appear
gratuitous. Most often the codes foster a collegial model of mutual
support that coincides with economic advantage and maintenance of
monopolistic control. The codes provide for a minimum of conflict and
maximize the possibility of aesthetic enjoyment of life. Few
professional organizations provide much support for their members who
suffer adverse consequences (loss of a job) for their stand in
conformity with the moral code of the professional organization but in
conflict with the self-interest of their colleagues. The nurse who
refuses an incompetent physician's order that would harm a patient and
is dismissed as a result is for all practical purposes left alone by the
professional organizations in attempting to do anything about the
injustice.
The codes have not been working well as of late for people have lost
faith in the power of the professionals with their technical limitations
and flaws. Past trust and success encouraged an increase in expectations
which could not be met. The public as consumers are increasingly
refusing to trust professionals. They are less willing to accept the
paternalistic attitude of the specially trained technician, the
physician or the nurse. Lack of trust, betrayal of confidence failure to
demonstrate continued progress and errors have led to the consumer's
demand for satisfaction, great clarity in the nature of the relationship
of consumer-producer, client-agent, patient-physician. The contract
model is now replacing and being urged as a replacement for the codal
model. In a democratic society especially, the civilized resolution of
differences is through the courts which rest upon laws and refer to the
terms of the contractual agreements between parties. Within this model
the parties must satisfy the terms of the contract – no more, or less.
Morality is equated with legality. Conformity to the letter of the law
is the ideal. Malpractice suits involving almost every profession are
the single most effective force encouraging the adoption of a
contractual model.
There is a third model, covenant, which could provide the basis for
addressing moral problems, but it is one which requires some socially
acceptable transcendent frame of reference in order to become operative.
Such a consensus as to a transcendent source of value and rights and
duties is difficult to obtain in contemporary democratic society with
ethical and religious pluralism become relativism and the weakened force
of religious beliefs.
However, such a model presents individuals as related in covenant
with one another. This relation cannot be broken and it requires
fidelity to the duties incurred because of the received gift of one's
life, opportunities of growth, and continued prosperity. In the covenant
model there is an existential element. Individuals undergo an
ontological change in status from ordinary members of society to
professional, for example, and it is not simply a nine to five
occupation but a change in life status which, in return for the
acquisition of specialized knowledge and skills and the privileges and
benefits of that professional practice, one incurs an obligation to
serve the welfare of the society that developed the talents and confers
the benefits. In Judeo-Christian traditions, God is viewed as the
ultimate source of the gift and corespondent obligations. The covenant
model involves the transcendent setting for principles, values, and
concerns that may serve personal reflection and ethical reasoning.
It further incorporates the fidelity ideal of the contractual model
and the collegial ideal of the codal model but provides the basis for
self-criticism and self-discipline within the professions since it
provides a higher obligation than service and defense of one's
colleagues. It not only permits but encourages individuals to report on
misconduct of colleagues and to effectively guard against malpractice
since the higher duty is toward the public welfare, humanity.
The formal preparation of technicians incorporates aspects of the
codal model and the so-called ethical components of business,
engineering, medical, and nursing texts have a good deal more to do with
legal responsibilities and contractual obligations than with moral
principles. There is little reference to values and the source of values
that could serve as the transcendent reference for the covenant model.
There is a need for the introduction into the formal preparation,
into the schooling or training of mechanics, technicians, professionals,
bureaucrats, physicians and nurses of a truly educational component that
would encourage the development of self-identity and the realization of
potentiality. Opportunities ought to be provided for value amplification
and clarification, ethical evaluation and deliberation, and aesthetic
sensitization and elaboration.
The educational institution ought to acknowledge that most people do
not live to work but work in order to live. The curriculum ought not
just prepare someone for a job but for life. A curriculum that aims at
preparing individuals for life ought to allow for and even require
experiences intended to assist individuals in dealing with and
incorporating the religious, philosophical, and artistic traditions that
underlie culture. In fostering cultural appropriation self-realization
would be promoted, while at the same time the individual would become
aware that there are costs and benefits extending beyond the particular
situation and involving more than self and that there are legitimate
concerns beyond professional and institutional interest: concerns for
principles, rights, values, and universal human welfare. The basis for
the covenant model would thus be developed.
Throughout the nursing profession there has been an ever-growing
awareness of ethical issues. At first, this was part of the general
increase in awareness in ethical problems faced by all health
practitioners and recipients (patients) and it continues to be the case
that most of the ethical discussions among nurses involve the general
issues in Bioethics or Medical Ethics rather than those specific
dilemmas faced especially by nurses, as were indicated above. Recently
there have been attempts to provide more ethical preparation for nurses.
However, recent surveys reveal that there are very few courses in
Nursing Ethics in the over l300 nursing schools in the United States.
There are a few such schools in college settings where courses are
purely elective. Moreover, reservations have been expressed about the
need for an entire course, questions raised about its possible
objectives, format, and its instructor's required background. There are
few texts available and most have been published only within
n the last three years. Several others are presently being prepared
for publication. There are courses in continuing education programs on
various issues in medical ethics with a focus on nursing, but they are
non-credit electives.
Occasionally, in service programs may have a presentation involving
ethical issues. Most of the resolution of moral problems appears to be
handled in informal discussions or through the matter of fact
recapitulation of some similar case as if to imply that, as such cases
have been handled in the past, they ought to be or will be in the
future.
In the health institutions such as hospitals and nursing homes, it is
extremely rare to find any individual or office or committee that is
formally designated as assisting in the discussion and resolution of
ethical issues or in preparing staff in handling such issues but
recently some have been introduced.
Within the professional organizations there is growing interest in
these issues and in the members’ ability to deal with them. The American
Nursing Association and several affiliated state organizations have
established committees or councils on ethical practice. State licensing
agencies have review boards that deal with illegal and unethical
practices. Several professional nursing journals regularly feature
articles and columns that describe moral dilemmas and address themselves
to the underlying ethical issues. There have also been a variety of
regional and national conferences on Nursing Ethics. Laudatory as all
this is, it has done little so far in terms of effecting the nursing
community, let alone nursing practice. Further, the situation in nursing
reflects and responds to the more general set of social instructional
problems.
There is much that could be done in terms of ministering to the needs
of those who are preparing to enter technical professions such as
nursing. Not the least of these needs is the development of critical
reasoning ability, moral principles, and ethical sensibility to assist
them in facing moral dilemmas and ethical issues. Introducing applied
ethics courses into the curriculum, sponsoring special programs
addressing ethical issues, guest lectures on ethics in and out of the
classroom, circulating articles treating ethical problems, raising the
consciousness of faculty and administrators as to these needs, leading
discussion sessions among students on ethical issues and many other
activities would be quite helpful. The possibilities for responding to
this call are limited only by the imagination. Any and all activities
that bring human values to consciousness in an age of technology are
most needed.