CHAPTER 10. Ethics in nursing
Megan-Jane Johnstone
LEARNING OBJECTIVES
• define nursing ethics
• outline the development of Western-based bioethics
• discuss the relationship between nursing ethics and Western-based bioethics
• explore a range of ‘everyday’ ethical issues that nurses might face in the course of providing nursing care to clients/patients, and
• discuss five areas in which a reexamination of the ethical issues faced by the nursing profession is warranted.
NURSING AND ETHICS
Nurses at all levels and in all areas of practice are confronted every day with having to make morally relevant choices and to take action on the basis of these choices during the course of their work. This ‘everyday’ occurrence should not be taken to mean, however, that deciding and acting morally in nursing care contexts is simply a matter of habit or ‘daily routine’, and therefore as something trivial requiring little knowledge, skill or attention. As can be readily demonstrated, dealing with everyday ethical problems requires of decision makers an exquisite moral sensibility, ‘moral knowing’, moral imagination, life experience, virtue (e.g. compassion, empathy, kindness, integrity, care, ‘decency’), general ‘informedness’ (e.g. about law, social and cultural processes, human psychology and behaviour, politics), and a deep personal commitment to ‘doing what is right’. In some instances ‘being moral’ also requires political savvy and an ability (personal and professional) to overcome the many obstacles that may obstruct or prevent morally just outcomes from being achieved.
Although it should be otherwise, there are times when deciding to act morally can require enormous courage and even ‘moral heroism’ on the part of those choosing to take a moral course of action. This is especially so in the case of nurses who, despite an apparent increase in professional status over the past several decades, continue to lack authority in their own realm of practice, continue to be burdened with enormous responsibilities without the lawful authority to fulfil them, and continue to be forced into silence when what they have to say on important ethical issues may threaten the status quo (Johnstone 1994, 2009).
All aspects of nursing (e.g. education, practice, management, leadership and research) have a profound ethical dimension. The ethical dimension of nursing (to be distinguished from the legal and clinical dimensions of nursing) has as its focus the inherent moral demands to:
• promote human wellbeing and welfare
• balance the needs and significant moral interests of different people
• make reliable judgments on what constitutes morally ‘right’ and ‘wrong’conduct, and
• provide sound justifications for the decisions and actions taken on the basis of these judgments.
Members of the nursing profession cannot escape these demands or the stringent responsibilities they impose. One reason for this is that no nursing decision or action (however small or trivial) occurs in a moral vacuum, or is free of moral risk or consequence—even the most ‘ordinary’ of nursing actions can affect significantly the wellbeing, welfare and moral interests of others. This is so whether in a nursing education, practice, management, leadership or research setting.
Nursing codes of ethics around the world make clear that nurses have a stringent moral responsibility to promote and safeguard the wellbeing, welfare and moral interests of people needing and/or receiving nursing care (Fry & Johnstone 2008). These codes also variously recognise the responsibility of nurses to balance equally the needs and interests of different people in healthcare contexts. What is often not stated, however, is how nurses ought to fulfil their moral responsibilities to deal effectively with the many ethical issues they encounter on a day-to-day basis. ‘Dealing effectively’ with ethical issues in this instance includes being able to:
• recognise both the short-term and long-term implications of these issues for the nursing profession generally, and
• develop strategies for responding effectively to these issues, once identified.
Dealing effectively with ethical issues in nursing also requires at least a rudimentary understanding of what nursing ethics is and its relationship to the broader field of Western-based bioethics.
WHAT IS NURSING ETHICS?
In advancing this discussion, it is important to first provide a brief definition of the notion of ‘nursing ethics’. Nursing ethics can be defined broadly as ‘the examination of all kinds of ethical and bioethical issues from the perspective of nursing theory and practice’ (Johnstone 2009:16). In turn, these issues rest on the agreed core concepts of nursing: person, culture, care, health, healing, environment, and nursing itself (i.e. what is it and what is its end or telos). In this regard then, nursing ethics is ‘not synonymous with (and indeed is much greater than) an ethic of care, although an ethic of care has an important place in the overall moral scheme of nursing and nursing ethics’ (Johnstone 2009:16).
Unlike other approaches to ethics, nursing ethics recognises the ‘distinctive voices’ that are nurses’, and emphasises the importance of collecting and recording nursing narratives and ‘stories from the field’ (Benner, 1991, Benner, 1994, Bishop and Scudder, 1990 and Parker, 1990). Collecting and collating stories from the field are regarded as important, since issues invariably emerge from these stories that extend far beyond the ‘paramount’ issues otherwise espoused by mainstream bioethics (to be identified shortly). Analyses of these stories tend to reveal not only a range of issues that are nurses’ ‘own’, but also a whole different configuration of language, concepts and metaphors for expressing them. As well, these stories often reveal issues that may have been overlooked or marginalised by broader bioethics discourse.
Given this, nursing ethics can also be described as ‘methodologically and substantively, inquiry from the point of view of nurses’ experiences’, with nurses’ experiences being taken as a more reliable starting point than other bioethics discourses (texts, practices and processes) from which to advance meaningful discussions on nursing ethics and the development of helpful processes for addressing ethical issues in nursing and related healthcare contexts (Johnstone 2009).
NURSING ETHICS AND ITS RELATIONSHIP WITH BIOETHICS
Contemporary nursing ethics has been profoundly influenced by the Western-based bioethics movement. Whether this influence has been advantageous to the development of nursing ethics, however, remains open to question.
In the English-speaking world, ∗ the term ‘bioethics’ first found its way into public usage in 1970–71 in the United States (Reich 1994). Although originally only cautiously accepted by a few influential North American academics, the new term quickly ‘symbolized and influenced the rise and shaping of the field itself’ (Reich 1994:320). Significantly, within three years of its emergence, the new term was accepted and used widely at a public level (Reich 1994:328). Today, both in lay and professional circles, bioethics (and all the issues commonly associated with it) has become the subject of major interest and debate.
Initially, the term ‘bioethics’ was used in two different ways. The first (and later marginalised) sense had an ‘environmental and evolutionary significance’ (Reich 1994:320). The other, competing sense in which the word ‘bioethics’ was used referred more narrowly to the ethics of medicine and biomedical research. Significantly, it was this latter sense that ‘came to dominate the emerging field of bioethics in academic circles and in the mind of the public’, and which remains dominant today (Reich 1994:320).
∗A German conceptualisation and usage of the term ‘bio-ethics’ (bio-ethik) dating back to 1927 has also recently been identified (Sass 2007). The German concept, like the first US conceptualisation of the field, ‘closely related nineteenth-century progress with the life sciences’ and, proposing a ‘bioethical imperative’, had as its focus the relationship of humans to animals and plants (Sass 2007).
The primary focus of contemporary bioethical debate tends to be on ‘the big’ issues such as abortion, euthanasia and assisted suicide, organ transplantation and reproductive technology. Other issues such as informed consent, privacy and confidentiality, the economic rationalisation of healthcare and research ethics have also all been comprehensibly debated in the bioethics literature since its inception in the 1970s. Not only has bioethics come to refer to and represent these and similar issues but, controversially, has positioned them as the most pressing (or ‘paramount’) bioethical concerns of contemporary healthcare in the Western world.
The nursing profession, like other healthcare professions, has responded proactively to the modern bioethics movement. Since the late 1970s, there has been a plethora of texts and journal articles published specifically on the topic of ‘nursing ethics’, in which a full range of the popular bioethical issues have been raised and explored. These works have made an important contribution to knowledge of the field, and have assisted many nurses in their quest to competently and confidently fulfil the many moral responsibilities associated with their professional practice. Nevertheless, the apparent and possibly obvious practical importance of bioethics to nurses, while recognised, is not without controversy.
One reason for this controversy relates to the dominance of the so-called ‘big’ ethical issues in the nursing ethics literature—a dominance that has sometimes resulted in other issues of greater relevance to the profession and practice of nursing being overlooked. For example, although a great deal has been written on the subject of promoting patients’ rights in healthcare contexts (e.g. the right to confidentiality, the right to give an informed consent to treatment, the right to die), comparatively little has been written on the subject of the role of nurses in promoting patients’ genuine wellbeing and welfare—which are sometimes compromised, paradoxically, in the interests of upholding their rights (Johnstone 2009). To cite another example, while much has been written on patients’ rights to refuse medical treatment at the end stage of life, comparatively little has been written on patients’ rights to request and receive healthcare at the end stage of life, including (and perhaps especially) the provision of high quality nursing care from appropriately qualified registered nurses.
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