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PARADIGM CASE
SARAH SHANNON, NURSE ETHICIST
I want to develop keels for them . . . they come oftentimes with pretty flat-bottom boats and the trouble with a flat-bottom boat is, when the wind blows, you just scatter across the water. And the wind blows this way, you scatter back across the water.
KNOWING HER STUDENTS will need to act ethically in situations fraught with conflict and confusion, Sarah Shannon explicitly focuses her teaching on formation. Using questions and dialogue, she challenges her students to thoroughly understand the clinical situation and facts of each situation. She engages them in a lively dialogue that helps them uncover their assumptions. There are high stakes in the teaching of ethics, and Shannon is clear that she wants her students to avoid the dangerous ethical shoals of complete relativism and subjectivism. She wants her students, as she says, to develop moral keels and self-understanding while at the same time respecting the values and perspectives of others—to become nurses who are inclusive and nonjudgmental.
Her accounts of teaching constantly point to her ultimate goal of formation. Although she has immediate content goals, they are always in the service of shaping nurses who will think and act ethically, who will respect the diversity of values and the ambiguity inherent in clinical practice, who will remember that right action in nursing is always about the patient.
I want them to come out of the course with a clear sense of their professional values. I talk a lot about [the fact] that professional values are the social contract we have with patients. They’re what every patient can expect when a nurse walks in the room, whether that nurse is young or old, male or female, black, white, regardless of their ethnicity, regardless of their religion, regardless of anything. It’s your social contract. For example, your personal value might be that you really like openness. Your professional value is that you adhere to confidentiality. That’s the contract with the patient.
Shannon, who has been teaching her ethics course for eight years, has an active and ongoing research and consulting career as an ethicist. Her passion for teaching ethics is evident: “I love teaching this course. . . . A lot of people struggle with how to teach this content . . . this shocks me when I find out that often it’s not a popular class with students in other programs, that they actually hate the class and find it boring. I’m dumbfounded…. [The students] want to do my readings: they’re fascinating.”
Her grasp of the subject is comprehensive and seasoned by her research practice and ethics and consultation practice. She admits the advantage she has in her teaching because of her immersion in and expertise about the subject she is teaching: “Everything I do is ethics: I teach ethics, my research is on ethics, yesterday I spoke on ethics.” However, she describes her development as a teacher as a difficult process. As a novice teacher, she tried to “cover everything.” She recalls scrambling to cover the proliferating issues in ethics and her gradual shift to a more process-oriented approach:
I would have this list of topics . . . I need to cover withdrawal of tube feeding, I need to cover stopping chemotherapy . . . I would just have lists and lists of all these issues. I packed the content in. What I’ve come around to is that I want them to learn a process that they can apply to another case. I also want them to learn what they don’t know, which is the hardest thing to teach people. Not that I’m going to teach them what they don’t know, but I want them to own what they don’t know. So, I want them to look at a case and . . . be able to say, “Well, I don’t know whether it’s painful to die of dehydration. Gosh, you know, I have this initial reaction, but do I have any evidence for that?”
In paying attention to her experiences in the classroom and what her students were learning and what they were not, Shannon recognized that her most important responsibility is to teach her students how to think ethically about taking care of patients, and how to separate their personal feelings about patients from their professional responsibilities to them. Once students understand how to think about ethical problems, she believes, they can act in an ethically responsible way.
The Case
Shannon conducts each class as a dialogue about the cases and related articles the students read in advance. The class session we observed was early in the term, at the point where she establishes the basic framework she and the students will use for analysis throughout the term, Jonsen’s fourfold ethical analysis structure (Jonsen, Siegler, & Winslade, 2002). In this particular class meeting, Shannon opened by asking the students to choose from among the cases they had read. They chose the internationally publicized Terry Schiavo case, with its attendant religious, political, and family controversies over withdrawal of fluids and nutrition from a young woman in a persistent vegetative state.
Shannon sets the classroom up so that students face each other. After she outlines the case, a student asks a question. Turning to the other students, Shannon asks, “What do you all think about that?” She uses that invitation to comment as a way of starting a conversation among the students. As the students discuss the case and their fellow student’s question, she does not intervene, letting them “dig their holes.” From time to time she says, “We’ll come back to this and talk about why this is an important distinction.”
Then she steps in and moves the discussion from the case to a more systematic approach, saying, “In ethical decision making, all of these questions come up. I want to give you a framework for thinking about these cases.” She outlines the Jonsen framework for clinical ethical decision making (Jonsen et al., 2002), telling them, “You are going to want to become facile in this.” Then she again walks the students through an analysis of the Schiavo case, this time using the Jonsen model.
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