Carrie Scotto
Symphonological bioethical theory
Gladys L. Husted1941 to present
James H. Husted1931 to present
“Symphonology (from ‘symphonia,’ a Greek word meaning agreement) is a system of ethics based on the terms and preconditions of an agreement”
(Husted & Husted).
Credentials and background of the theorists
Gladys Husted was born in Pittsburgh, where her life, practice, education, and teaching continue to influence the nursing profession. Husted received a Bachelor of Science in Nursing degree from the University of Pittsburgh in 1962 and began practice in public health and acute inpatient medical-surgical care. Observations of interactions between nurses and patients initiated her interest in ethical issues. In 1968, she earned a master’s degree in nursing education while teaching at the Louise Suyden School of Nursing at St. Margaret’s Memorial Hospital in Pittsburgh. Her love of teaching prompted doctoral study that resulted in a terminal degree from the University of Pittsburgh Department of Curriculum and Supervision.
G. Husted is currently professor emeritus at Duquesne University School of Nursing, where in 1998 she was awarded the title of School of Nursing Distinguished Professor. She continues to teach part time and direct dissertations. The school has also recognized her teaching excellence at all levels of the curriculum through the Duquesne University School of Nursing Recognition Award for Excellence 1990/1991 and the Faculty Award for Excellence in Teaching 1994/1995. The Medical College of Ohio chose Husted as Distinguished Lecturer in 2000. She is a member of Sigma Theta Tau International, Phi Kappa Phi, and the National League for Nursing.
G. Husted served as consultant for Western Pennsylvania Hospital Nursing Division regarding the development of an ethics committee, including educating staff and management, and providing guidance for the newly formed committee. She also provided consultation for the Allegheny General Medical Center for staff development and the National Nursing Ethics Advisory Group for the Department of Veterans Affairs. G. Husted served as curriculum consultant for several schools of nursing. In addition, she has presented at many national-level conferences.
James Husted was born in Kingston, Pennsylvania, and has had a lifelong interest in philosophy. While in the army in Germany, he became interested in ethics through conversations with a former ethics professor, particularly the work of Benedict Spinoza.
J. Husted’s post-Army career focused on sales and on hiring and training agents for health insurance companies. However, he continued to read and develop his philosophical and ethical ideas. During the 1980s, he joined the high-IQ societies, Mensa and Intertel, serving as a philosophy expert for Mensa and a regional director for Intertel.
The theorists met and were married in 1974, establishing and cultivating a dialogue that brought about the theory of Symphonology. They are coauthors of several editions of Ethical Decision Making in Nursing. Their book was selected as one of Nursing and Health Care’s Notable Books of 1991, 1995, and 2001. It also won the Nursing Society Award in 2001. Their regular column, “A Practice Based Bioethic,” appeared in Advanced Practice Nursing Quarterly from 1997 to 1998. In addition to publishing books, book chapters, and journal articles, they have presented their ethical theory at conferences and workshops.
The Husteds reside in Pittsburgh and continue to develop and disseminate their work through teaching, writing, presenting at conferences and workshops, and serving as consultants for ethics committees.
Theoretical sources
The authors define Symphonology as “the study of agreements and the elements necessary to forming agreements,” (Husted & Husted, 2008, p. xv). In health care, it is the study of agreements between health care professionals and patients. An agreement is based on the nature of the relationship between the parties involved. In its ethical dimensions, it outlines the commitments and obligations of each. Although the theory developed from the observation of nurses and nursing practice, it later expanded to include all health care professionals. The development of this theory has led to the construction of a practice-based decision-making model that assists in determining when and what actions are appropriate for health care professionals and patients. The name of the theory is derived from the Greek word symphonia, which means “agreement.”
Ethics is “a system of standards to motivate, determine, and justify actions directed to the pursuit of vital and fundamental goals” (Husted & Husted, 2008, p. 8). Ethics examines what ought to be done, within the realm of what can be done, to preserve and enhance human life. The Husteds, therefore, described ethics as the science of living well.
Bioethics is concerned with the ethics of interactions between a patient and a health care professional, what ought to be done to preserve and enhance human life within the health care arena. Within the past century, the expanding knowledge base and growth of technology altered existing health care practice and created threatening and confusing circumstances not previously encountered. Increasing numbers and types of treatment options allowed patients to survive conditions they would not have in the past. However, the morbidity of the survivors brought new questions: Who should receive treatment? What is the appropriateness of treatments under particular circumstances? Who should decide what treatments are appropriate? In this way, bioethics became a central issue in what previously had been a prescriptive environment. It became essential to consider ethical concerns, as well as scientific solutions, to questions of health (Jecker, Jonsen, & Pearlman, 1997). Through personal experience and observation of nurses, the Husteds recognized the increasingly complex nature of bioethical dilemmas and the failure of the health care system to adequately address the problem.
To clarify the reasons for the deficiency of the health care system in addressing the issue of delivering ethical care, the Husteds examined traditional ideas and concepts used to guide ethical behavior. These ideas include deontology, utilitarianism, emotivism, and social relativism. Deontology is a duty-based ethic in which the consequences of one’s actions are irrelevant. One acts in accordance with preset standards regardless of the outcome. The inappropriateness of this type of guideline is obvious in relation to health care professionals, because they are responsible for foreseeing the effects of their actions and acting only in ways that benefit a patient. Utilitarian thought would have health care professionals acting to bring about the greatest good for the greatest number of people. This is inconsistent with the practice of health care professionals who act as agents for individual patients. Emotivism promotes ethical actions in accordance with the emotions of those involved. Rational thought has no place in emotive choices, making this type of decision-making process inappropriate in the health care arena. Social relativism imposes the beliefs of a society onto the individual. This approach is incongruous with the increasing diversity of our emerging global society. The authors recognized that the inappropriateness of traditional methods of ethical reasoning brought about the failure of the health care system to successfully address bioethical issues.
Because traditional models proved inadequate to guide ethical behavior for health care professionals, the Husteds began to conceive and develop a method by which health care professionals might determine appropriate ethical actions. The theory was based on logical thinking, emphasizing the provision of holistic, individualized care. They drew from the work of Aristotle, Benedict Spinoza, and Michael Polanyi. These philosophers adhere to rational thought and value persons as individuals. Aristotle was a student of Plato who advanced his teacher’s work by recognizing that there is more to understanding phenomena than simple rationality. He believed that one must develop insight and perception to recognize how principles can be applied to each situation (McKeon, 1941).
The Dutch philosopher, Spinoza, examined the nature of humans and human knowledge. He recognized that, although the process and outcomes of reasoning may be comparable for each person, intuitive and discerning thought is unique to each. Spinoza believed that reason must be coupled with intuitive thought for true understanding (Lloyd, 1996). Spinoza was noted for taking well-worn philosophical concepts and transforming them into new and engaging ideas. This is true of the Husteds’ development of Symphonology, particularly in the evolution of the meaning of the bioethical standards.
Polanyi proposed that understanding is derived from awareness of the entirety of a phenomenon, that the lived experience is greater than separate, observable parts. Tacit knowledge, that which is implied, is necessary to understand and interpret that which is explicit (Polanyi, 1964). These concepts, the uniqueness of the individual and the extension of reason and rationality with insight and discernment to create true understanding, are the foundations of the symphonological method.
Use of empirical evidence
Study and dialogue between the two theorists, coupled with experience of the overall evolution of health care and observation of individual nurse-patient relationships, provided the impetus to develop Symphonology Theory. G. Husted’s dissertation focused on the effect of teaching ethical principles on a student’s ability to use these in practical ways through case studies. J. Husted was very instrumental in the selection of the dissertation topic and was used as a consultant during the process. Development of G. Husted’s doctoral work led to numerous publications and presentations before the first edition of the book Ethical Decision Making in Nursing was published in 1991. This first edition presented their work as a conceptual model only. As they continued to develop their ideas, incorporating feedback from graduate students, the Symphonological theory emerged. Before publication of the second edition, the Husteds (1995a) continued to clarify the theoretical concepts and developed the model for practice.
Beginning in 1990, Duquesne University offered a course devoted to this bioethical theory. The authors continued to seek critique and examples about their work from students, practitioners, and other experts. The third edition of the book, Ethical Decision Making in Nursing and Healthcare: The Symphonological Approach (Husted & Husted, 2001), offered a clarified description of the theory, with advanced concepts separated from the basic concepts. In addition, the model was redrawn to better represent the nonlinear nature of the theory in practice. The fourth edition offers further clarification of concepts and the integration of concepts in the theory as a whole. In addition, the text is rearranged to present the concepts from simple to more complex.
As the theory emerged, the need for an emphasis on the individual became apparent and essential. In recent years, it has become accepted practice in the literature to designate patients and nurses as “he/she,” or simply use the plural form, referring to nurses and their patients. The authors recognized that these awkward and anonymous terms distract readers from thinking in terms of real people within the context of a particular situation. Therefore, they chose to refer to individuals as he, in the case of patients, and she, in the case of health care professionals in particular situations and examples. This chapter will continue with this practice.
Major assumptions
The assumptions from this theory arise from the practical reasoning. The model is meant to provide nurses and other health care professionals with a logical method of determining appropriate ethical actions. Although many of the terms are familiar to nurses and health care professionals, some have been redefined to support the reality of human interaction and ethical delivery of health care.
Nursing
Symphonology holds that a nurse or any other health care professional acts as the agent of the patient. Using her education and experience, a nurse does for her patient what he would do for himself if he were able. Nursing cannot occur without both nurse and patient. “A nurse takes no actions that are not interactions” (Husted & Husted, 2001, p. 37). The nurse’s ethical responsibility is to encourage and strengthen those qualities in the patient that serve life, health, and well-being through their interaction (Fedorka & Husted, 2004).
Agency is the capacity of an agent to take action toward a chosen goal. A nurse as agent takes action for a patient, one who cannot act on his own behalf. The shared goal of a nurse and a patient is to restore the patient’s agency. The nurse acts with and for the patient toward this end.
Person or patient
The Husteds define a person as an individual with a unique character structure possessing the right to pursue vital goals as he chooses (Husted & Husted, 2001). Vital goals are concerned with survival and the enhancement of life. A person takes on the role of patient when he has lost or experienced a decrease in agency resulting in his inability to take the actions required for survival or happiness. The inability to take action may result from physical or mental problems, or from a lack of knowledge or experience (Husted & Husted, 1998).
Health
The authors do not address or define health directly. The entire theory is driven by the concept of health in the broadest, most holistic sense. Health is a concept applicable to every potential of a person’s life. Health involves not only thriving of the physical body, but also happiness. Happiness is realized as individuals pursue and progress toward the goals of their chosen life plan (Husted & Husted, 2001). Health is evident when individuals experience, express, and engage in the fundamental bioethical standards.
Environment or agreement
The environment established by Symphonology is formed by agreement. “Agreement is a shared state of awareness on the basis of which interaction occurs” (Husted & Husted, 2001, p. 61). Agreement creates the realm in which nursing and all other human interactions occur. Every agreement is aimed toward a final value to be attained through interactions made possible by understanding.
The health care professional–patient agreement is formed by a meeting of the professional’s and the patient’s needs. Their agreement is one in which the needs and desires of the patient are central. The professional’s commitment is defined in terms of the patient’s needs. Without this agreement, there would be no context for interaction between the two. The relationship would be unintelligible to both (Husted & Husted, 1999).
Symphonology Theory is not a compilation of traditional cultural platitudes. It is a method of determining what is practical and justifiable in the ethical dimensions of professional practice. Symphonology recognizes that what is possible and desirable in the agreement is dependent on the context.
The context is the interweaving of the relevant facts of a situation—the facts that are necessary to act upon to bring about a desired result (Husted & Husted, 2001). There are three interrelated elements of context: the context of the situation, the context of knowledge, and the context of awareness. The context of the situation includes all facts relevant to the situation that provide understanding of the situation and promote the ability to act effectively within it. The context of knowledge is an agent’s preexisting knowledge of the relevant facts of the situation. The context of awareness represents an integration of the agent’s awareness of the facts of the situation and her preexisting knowledge about how to most effectively deal with these facts (Husted & Husted, 2008).
Theoretical assertions
Symphonology is classified as a grand theory because of its broad scope. Grand theories structure goals related to a specific view of the discipline (Walker & Avant, 2011). Grand theories are broader than conceptual models and may be used as a model to guide practice and research (Fawcett & Garity, 2009). The authors developed Symphonology Theory not from natural progression of other work, but from the recognition of a need for theoretical guidelines related to the ethical delivery of health care. The understanding and use of this theory are based on a fundamental ethical element that describes the rational relationship between human beings: human rights.
Rights
The Husteds describe rights as the fundamental ethical element. Traditionally, rights are viewed as a list of options to which one is entitled, such as a list of items or actions to which one has a just claim. Symphonology holds rights as a singular concept. It is the implicit, species-wide agreement that one will not force another to act, or take by force the products of another’s actions. Rights are viewed as the critical agreement among rational people, the agreement of nonaggression (Husted & Husted, 1997a). This agreement emerged as humans became rational and developed a civilized social structure. A nonaggression agreement is preconditional to all human interaction. It serves as a foundation on which all other agreements rest. The formal definition is as follows: “the product of an implicit agreement among rational beings, held by virtue of their rationality, not to obtain actions or the products of actions from others except through voluntary consent, objectively gained” (Husted & Husted, 2001, p. 4). The operation of this is evident in human interaction.
According to the Husteds, Symphonology Theory can ensure ethical action in the provision of health care. Agreement is the foundation of Symphonology. Agreements can occur based on the implicit understanding of human rights. The understanding of nonaggression that exists among rational persons constitutes human rights. This understanding makes negotiation and cooperation among individuals possible.
Ethical standards
Ethical standards have been the benchmarks of ethical behavior. The standards include terms familiar to health care professionals such as beneficence, veracity, and confidentiality. However, the authors have conceived new meanings for ethical standards that correspond to the foundational concepts of Symphonology: the person as a unique individual, and the use of insight and discernment in addition to reason and rationality in order to achieve a deeper understanding.
Traditionally, bioethical concepts have been used to guide ethical action by mandating concrete directives for action. For instance, the concept of beneficence conventionally maintains that one must see that no harm comes to a patient. However, it is not always possible to predict how and when harm will occur, making adherence to this directive an unrealistic goal. The concept of beneficence, viewed as a mandate, could also imply that defending yourself against a physical attack is unethical. Similarly, veracity, or truth telling, holds that one must always speak the truth regardless of the consequences. Therefore, it is unethical to withhold potentially harmful information, regardless of the consequences. Adhering to veracity may interfere with one’s commitment to beneficence. Clearly, ethical standards taken as concrete directives do not allow for the consideration of context.
The authors have redefined the ethical standards, not as concrete rules, but as human qualities or character structures that can and must be recognized and respected in the individual (Husted & Husted, 1995b). For example, in Symphonological terms, beneficence includes the idea of acting in the patient’s best interest, but it begins with the patient’s evaluation of what is beneficial. In this way, ethical standards are presuppositions in the health care professional–patient agreement and ethical guides to decision making. The participants work together with the implicit understanding that each is possessed of human characteristics. The description and names of the bioethical standards have changed over time based on feedback from practitioners. Symphonological theory holds that patients have a right to receive the benefits specified in the bioethical standards. Box 26–1 provides definitions and examples of bioethical standards.
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