Journal of Advanced Nursmg, 1992,17,129-137

Differences in ethical decision-making processes among nurses and doctors Rivka Grundstem-Amado RN PhD Project Co-ordmator, Baycrest Centre for Gertatnc Care, Competency Clinic, Department of Psychiatry, 3560 Bathurst Street, North York, Ontario M6A 2El Canada

Accepted for publication I July 1991

GRUNDSTEIN-AMADO R (1992) Journal of Advanced Nursmg 1 7 , 129-137 Differences in ethical decision-making processes among nurses and doctors The study reports results of an inquiry into the different patterns of ethical decision making used by doctors and nurses The findings of the study are that nurses and doctors act out of different values, motivations and expectations and that there is a communication gap between them Nurses place the highest value on the 'canng' perspective, which entails responsiveness and sensitivity to the patients' wishes In contrast, the doctors value above all the patients' nghts and the scientific approach that implies a major concern with disease and its cure The study suggests that there is a need for the development of a new foundation, based on common professional attnbutes of the two groups, to which both groups are committed This would provide a joint point of reference from which the two professions can solve shared ethical problems and would remove communication barriers

INTRODUCTION This paper reports the results of an inquiry into pattems of ethical decision-making processes adopted by nurses and doctors in the health care system The study attempts to provide cin ln-depth descnption and understanding of how nurses and doctors make ethical decisions in the light of ethical and decision-making theory An analysis of the vanous pattems exhibited by the two professional groups can be conducive to promoting better ethical practice and enhancing effective lines of communication between doctors and nurses It is important to note that this issue has received very little attention in the literature The framework that guided the inquiry, the method, analysis and interpretation of the data are outlined m the subsequent sections of this paper

THE CONCEPTUAL FRAMEWORK This study provides a model for dirucal ethical deasion making (Grundstem-Amado 1990,1991) The model serves

as a conceptual framework and as a standard for comparing health care providers' (HCPs) reports about their ethical decision-making processes The model is composed of three maj or elements the ethical component, the decision-making component and the contextual component The latter compnses the relational aspects between the provider and the patient as well as the organizational structure The model suggests that m order to amve at a sound, morally defensible decision one makes reference to those three elements This study, then, examines and assesses to what extent nurses and doctors as two groups of health professionals differ from one another in relation to the three dimensions of the model The first component of the model is the ethical framework, which IS determined by the individual's moral reasorung structure Moral reasoning is hierarchical and begins with a particular value judgement based on the individual's value system These vcdues are justified in vanous ethical pnnciples which cire ultimately grounded in ethical theories (Beauchamp & Qiildress 1983) More speafecally, value theory generates three mam principles 129

R Grundstem-Amado

autonomy, bene&cence and justice These three accepted principles can be implemented by combining two major ethical theones deontology and teleology (GmndsteinAmado 1991) The second component of the model is composed of the decision-making procedure hsting the steps that one should take m order to reach the final course of action The following eight steps are (a) problem perception, (b) information processing, (c) identification of the patient's preferences, (d) identification of the ethical issues, (e) listing of f>ossible altemahves, and (f) their consequences, (g) the selection of a chosen course of action, and (h) finally its justification The contextual component of the model is composed of (a) the relationship between the patient and the provider and (b) the impact of the organizational structure on the HCPs' ethical behaviour

METHODOLOGY The study was conducted with 18 health care providers (nme female nurses and rune male doctors) in two Toronto hospitals An effective companson between the two professional groups was provided which by and large conformed to the sexual division The partiapants vaned in their ages, their years of expenence, and their specialization The doctors were selected fTom three areas Three doctors were from the family practice field, another three were from mtemal medicine and three were from long-term care All of the doctors in the sample had more than 10 years exfjenence Nurses were selected from two cireas of the two hospitals five nurses worked within long-term care and the other four worked m an acute-care setting Five nurses had more than 15 years of expenence and the other four nurses had less than 5 years One nurse functioned as a nurse manager and all the others worked as staff nurses One doctor served as a medical director of the hospital and the others worked both within the hospital setting and as pnvate practitioners

DATA Data were collected through two-phased, m-depth, semistructured interviews The general framework of the interview method is adopted from Encsson & Simon's (1984) model They make a clear distinction between information based on past situations (ie from long-term memory) and information that is generated and produced through responses to hypotlwhcal situations (l e from short-term 130

memory) Following this device, the interview was divided into two phases comprising two forms of reporting retrospection with regard to past expenence and response to a hypothetical situation In phase one of the interview, the questions were unstructured, containing open-ended questions, allowing an analysis of the HCPs' past personal expenence with ethical decision-making processes The participants' value systems and their references to ethical pnnciples and theones, their pattems of decision-making processes and their references to the vanous relational modes and organizational aspects were analysed The second phase of the interview probed the participants' responses to a hypothetical case (see Appendix) in which systematic, structured, sequentied questions were asked following the proposed model The two data sets served as a base m which the two modes of responses complement each other and are most likely to yield direct evidence of the HCPs' ethical decision-making processes Employment of the two methods made achieving completeness in the reports more likely

Quality of the data Since this study involved interpretation by the researcher, it IS unlikely that there were no errors or biases In order to minimize errors, and to increase reliability and validity, certain precautions were undertaken All of the interviews were tape-recorded and transcnbed The transcnptions of the interview were passed on to another evaluator for the purpose of venfication of the researcher's interpretation By reaching an agreement on the interpretation of the wntten responses, the credibility of the data was increased

RESULTS The study examined and assessed to what extent the two professional groups differ from each other in relation to the three components of the model The data from the two sets of interviews with the HCPs are reported in three sections The first section concems the ethical framework the second, the decision framework and the third, the contextual framework However, this paper will focus pnmanly on two components of the model (l e the ethical framework and the decisionfrcunework)since limited space precludes detculed reporting of the third component (l e the contextual component) In addition, it is important to note that due to the small sample size, firm generalization beyond the sample could not be made

Ethical dectsion-maktng processes

Table 1 Ethical analysis of nurses' and doctors' expressed values HCP's past expenence Values Basic values Survival Dignity Self-respect Knowledge Quality of life Comfort Respect for Patient wishes Patient nghts Moral values Carefulness Responsibility Truthfulness Honesty Courage Avoid harm Soaal values To inform Co-of>eration Equality

HCPs response to hypothetical case Nurse

Doctor

3 6 0

1

0

6 3

3 6

3 0

0 3

'Be careful and selective about what you say' 'Do not abandon the patient' 'Do not he, be true as possible' 'Do not shy away from explaining the treatment' 'In medicine you have to take nsk' 'Do not harm the patient'

2 0 4 3

3 3 3 1

3

2

1 2

1 5

0 3

1 3

'Share mformation' 'I don't believe in vertical line of authonty, I believe in partiapation' Treat the patient as equal'

7 4

8 3

2

2

Illustration

Nurse

Doctor

'If there is any potential for Me and hope I will resuscitate' 'I believe in humanitarian approach toward death' Treating other people the way you treat yourself' 'Increase your knowledge, up to date' 'I will always value quality vs quantity' T o ease pain'

0

2

8

3

4

0

1 3 6

'Respect the patient's wishes to die' 'Resp)ect patient's confidentiality'

The ethical framework The analysis of th(; ethical component consisted of a descnption of the slubjects' statements values and their implicit reference to ethical principles and theones Values were classified into Beck's value framework (Beck 1984) basic human values,, moral values and social values As displayed m Table 1, a set of 17 values emerged in those three categones The meeinmg of each value was illustrated by a direct quote from the vanous participants' comments (the direct quotations present in this paper were identified by assigning each doctor a letter code (A), and each nurse a number code (I) Values were identified as dominant on the basis of the highest number of HCPs reporting each value in each professional group Dominant values in phase one of the interview (the HCPs' own past expenence) were compared to dominant values m phase two (the hypothetical case) The consistency of each HCP's responses between

Table 2 Nurses' and doctors' ethical framework

HCP's past expenence

HCPs' resDonse to hypothetical case

Ethical aPDroach

Nurse

Doctor

Nurse

Doctor

Deontology Teleology Mixture

6 3 0

6 3 0

3 3 3

3 3 3

the two phases was examined From these two different modes of analysis, pattems of ethical approaches used by HCPs m their decision-making processes emerged (see Table 2) Speafically, from the list of values mentioned by 131

R Grundstein-Amado

nurses and doctors it was possible to make inferences about their moral-reasoning processes (Beck 1984) that is, whether they appealed to the prmaples of beneficence, patient autonomy and justice Such prmaples are lmpliatly grounded m ethical theones such as deontology — or teleology For example, if the HCPs valued the most basic human values (l e respect for patients' nghts, digruty and survival), those values are prominently grounded m the pnnaple of patient autonomy, and hence they identified ultimately with the deontology theory Alternatively, if the HCPs valued most moral values such as 'avoid harm' they lmpliatly appealed to the pnnciple of beneficence that is grounded in teleology In nurses' own past expenence (phase one), it seems that they valued most the patient's wishes for 'autonomy' and 'self-determination' Moral and soaal values were the least important to them (see Table 1) For example, m the basic human values category, the values that figured prominently among nurses were 'dignity', 'comfort' and 'respect for the patient's wishes' The least mentioned values were 'survival' and 'knowledge' In the second category — moral values — the value of 'truthfulness' dominated the nurses' responses and the least dominant were the values of 'responsibility' and 'courage' Altematively, in the doctors' group, in the basic human values category, the equally most frequent values were 'quality of life' and 'respect for the patient's nghts' The least important value reported was 'self-respwct' In the second category — moral values — the dominant value was to 'avoid harm' and the least mentioned were 'honesty' and 'courage' In the last category — soaal values — nurses and doctors share almost equally the value 'to inform' The value least emphasized by both groups was 'equality' The responses to the hypothetical case revealed an emphasis on different values Within both groups the dominant values were moral values, such as 'carefulness' and to 'avoid harm', the less dominant were soaal values

Second, the nurses could follow the traditional view of subordination to the dominant authonty, thereby excusing themselves from any responsibility that the deasion might entail, passively accepting other people's judgement Third, the nurses could offer a compromise that integrated their own beliefs with their concem for the organizational constraints of their work place, in order to seek an equilibnum between the patients' needs and these constraints For example, nurse (III) comments I would follow the compromise—the patient will feel less sick, the family will feel that something has been done to the patient you are not going full force, so the harm is not so

bad The general ethical picture that emerged from the doctors' group highlighted some ambiguities as well These results indicate that, although the physiaans were not bound by any formal procedures of decision making and in fact were the ones pnmanly responsible for the well-being of the patient, they also adopted three ways of dealing with ethical problems One way was to let the patients choose and make their own deasions Accordingly, the doctors' role was to provide input only through advice and consultation, thereby delegating the decisional authonty to the patient For example, Dr (I) claims 'I cim not a decision maker, I am an adviser My decision is not to make the deasion' The second way of dealing with an ethical problem was to act as an intermediary and faalitator among different parties involved in the deasion-making process, such as the family and other professional groups For example, doctor (B) conunents 'I am a co-ordmator, my job is to smooth things out' The third way was to take an ethical stance and utilize 'defensive medicme' In other words, the doctors needed to justify their decision by referrmg to a solid foundation such as adherence to certain legal procedures using medical knowledge, rather than m accordance with the patients' wishes

Three ethical approaches

Three ethical approaches emerged from both data sets deontology, teleology and a mixture (see Table 2) The general picture provided of nurses' and doctors' ethical frameworks highlighted some distinct ambiguities When the nurses were faced with an ethical dilemma (hypothetical case) they adopted three possible approaches First, the nurses could use their own personal beliefs and independent moral thinking, in order to fulfil their needs to dioose and reason freely and to treat the patient the way they thonselves would want to be treated within the organization. 132

The decision framework Withm the deasion framework, the significant differences that emerged between nurses and doctors are only m the followmg steps the information processmg stage, the ldenbfication of the ethical issues, and m the process of selection and justification of their deasions (see Table 3) Information processmg

In companson with the doctors, the nurses required more information related to the patient's feelmgs, copmg

Ethical decmon-mahng

processes

Table 3 Deasion analysis

HCP's response to hypothetical case

HCP's past expenence

Information processing Utilizing extensive information Utilizing modest information Seeking for other sources of information Patient preferences Being able to identify the patient's preferences The ethical issues Refuse to treat To go against your duty to 'do no harm' Palliative care vs terminal care Cost vs benefit Who should deade? Patient properly informed Mistrust Patient choice vs professional advice Being able to identify the ethical issues The choice To give the treatment Not to give the treatment Palliative care Partial treatment Non-traditional therapy Second opinion Not being able to choose Justification Based on medical knowledge Based on belief system Based on expenence Based on consequences Not being able to justify

mechanisms, life history and the dynamics of the relationship between the family and the patient In contrast, doctors requested mamly medical techrucal details in order to construct an accurate picture of the problem For example, when one of the nurses (nurse II) was asked whether she needed more mfoimation than that presented m the hypothetical case, she answered 'I need to know the family background and their fight through the derual', and another nurse (nurse IV) answered 1 need to know the religious badcground of the patient and his/her expenence with life and death' However, as opposed to nurses, doctors sought

Nurse

Doctor

Nurse

Doctor

3 2

5 2 7

5 4

0

4 2 1

7

4

9

3

1 2 1

0 3

2 2

3 1 2 I

0 2

I 1

3 1 2 2

4 3 0 I

0

0 1

4

8

5

4

1 0

3

0 4 4

2 5 0

2 4 1

I 0

0 2

I 1

4

3 0 0 2

mainly technical information related to the disease process For example, Dr (B) comments 'I need more confirmation of the diagnosis, I want to make sure that the diagnosis is correct' These findings can be explained by the HCPs' motivation to support theirfinaldeasions As mentioned previously m the ethical analysis, the maj onty of the nurses chose to value above all the patient's wishes, consistent with their moral approaches In attempts to support their decisions they looked for other (non-medical-techrucal) sources of lnfonnation that might provide justification 133

R Grundstem-Amado

But the findings might also be analysed from a gender perspective For example, Gilligan (1982) claims that while women reconstruct hypothetical dilemmas they tend to search for missing mformational sources about people's nature and their livelihood Similarly, Noddmg (1984), claims that women need to see people's eyes and their faaal expressions in order to form an accurate picture of real-life moral situations Accordingly, it is possible to infer that nurses (who, as mentioned earlier, by and large conform to this sexueJ division) generally construct the ethical problem as an issue of response to the patient's needs, that can be symbolized through vocal or non-verbal communicative messages Thus, nurses attempt to mamtam and sustain a relationship that reflects the patient's own speafic terms and contexts In an attempt to solve the ethical problems, nurses will search for vivid indications of patient's feelings, intentions and interests and will not necessanly invoke any rules of equality cind justice Within the doctor's group, the process of searchmg for other sources of information was less important, some of the doctors claimed that the information presented in the case descnption was sufifiaent for them to reach a decision Thus, the limited information that was available in the presentation of the hypothetical case served as an adequate source to meet the needs of the situation, l e the construction of the moral problem as a conflicted issue that needed to be resolved Doctors will talk to the patient and will try to understand the patient's world view and the patient's dnving force but will not necessanly act in a responsive manner Doctors attempt to establish a relationship that can be descnbed as an interaction between two separate individuals who aim to resolve together an ethical problem One party represents informative medical standards, l e professional knowledge, and the implicit interests of soaety The other party represents a moral claim on the physician's knowledge in order that he/she may be fully treated and healed The information which generates the knowledge held by doctors is seen as impersonal and uruversal, based on established ideas of medical practice and patient nghts However, the contrasting pattem held by nurses is based on knowledge generated through personal touch and concrete mteraction with the patient In support of these findmgs about nurses, one may refer to Hagell's (1989) assertion that nursmg has a distinct knowledge base The knowledge is not grounded in empincoanalytic soence but st«ns from the lived expenence of nurses as women and as professionals mvolved m canng relationships with their clients (Hagell 1989) 134

77ie ethical issues

In identifymg the ethical issues mvolved with the deasionmakmg situation, it emerged that m the HCPs' own expenence only eight nurses and four doctors were able to identify the ethical issues involved in descnbmg their confrontation with ethical problems In response to the prompted case the nurses, as a group, identified slightly more of the ethical issues than the doctors, as a group, did Based on reports of past expenence and the HCPs' responses to the prompted case, the findings suggest that nurses tend to expenence a greater tendency to moral sensitivity than do doctors Moral sensitivity can result from either their having no power to control the action and to act as a free moral agent, or from their inclination to support and sustain the patients who faced difficult moral choices These two factors can contnbute to nurses' moral distress, a phenomena defined by Jameton (1984) in which nurses feel that they have to sacnfice emd compromise their lntegnty because of their peculiar position in the health care power structure and because of their conflicting loyalties and responsibilities Workmg within a bureaucratic setting may produce certam traits of character which can ciffect the way people think and mteract Ferguson (1984) claims that 'compassion, generosity and sensitivity to others are crucial values that are more often found m the oppressed than among the oppressors' (Ferguson 1984) Sensitivity towards ethical issues is one of the attnbutes that may result from the nurses' workplace environment Oppression may produce both positive and negative effects On the negative side it may cause avoidance of the patient and may paralyse nurses' ability to care for the patient and be attentive to the patient's needs On the positive side it may increase the nurses' awareness of, and alertness to, moral issues, and consequently reinforce feelings of empathy and compassion towards the patient

The choice

The act of choice is the culmination of the entire process of deasion making, the point at which all the vanous attnbutes that affect deasion making are channelled together mto one statement the moral choice The deasion maker finally makes the deasion that has already been constructed m his/her mmd This act is determined by the amount of knowledge the deasion maker holds, his/her cognitive capaaty and his/her moral approach In this category, differences among nurses and doctors ako emerged In response to the hyjrothetical case, four doctors chose to treat, three doctors chose not to treat, one

Ethical decision-makmg processes

doctor chose to send the patient to a different agent and one doctor chose the 'partial treatment option' Within the nurses' group, three chose to treat, one nurse chose not to treat, three nurses offered a compromise treatment, such as 'partial treatment' and a 'second opinion', and two nurses offered 'palliative care' For example, Dr (D) asserts

For example, nurse (I) chose to give the treatment to the patient She followed her belief that adhenng to the patient's wishes and values will be best for the patient Her concem was stnctly to respect the patient's wishes and this was reflected m her choice Altematively, nurse (VIII) valued most those moral values which entailed a closer attention to professional 'My decision is not to give the treatment by givmg the behaviour m avoidmg mistakes or undesirable consetreatment I will achieve satisfaction for short-term goal but m quences In her choice she preferred to go slowly, hoping the long run the consequences will be unacceptable Based on that the patient would realize that the proposed treatment my knowledge, the Mopp will make the patient very sick and was harmful and subsequently withdraw or decline his/her it won't change the course and the prognosis of her disease, and she will die sooner I can't pretend that I don't know that' request

In contrast to Dr (D) another doctor (B) comments My ultimate decision is to carry out what the patient and the family want and wish If the patient insists on receiving the treatment I will go with it' The nurses vaned in their choices For example, nurse (I) comments I would give the patient the treatment you have to give the patient some incentive, something to go on you give them fight and encouragement Another nurse (VI) asserts I will give them only pain relievers to alleviate the discomfort I believe in letting the patient die in a human way and with dignity I want to help the patient to fulfil her last task in life — to die' Another nurse (VIII) comments I will treat the patient partially, for the reason of protection, to show the patient and the family that I am doing what they wish and at the same time, while the patient expenences the treatment and its consequences, they might realize that I was nght so nobody will feel guilty [that nothmg was being done] These findings indicate how the HCPs stated the choices that related to their values and moral stances Analysing the data presented in this category revealed that there was a direct relationship between the ethical stances HCPs espoused and their ultimate choice HCPs carry welldefined value systems which give nse to the final judgement and may minimize their consaous decision-making process

Justification

The last step of the decision-making process was the act of justifying the ultimate choice This step was fundamental for the validity and appropriateness of the moral deasion and it involved the application of the relevant ethical rules and theory The individuals were faced with the need to explam and defend their judgement Their ability to justify their choices and provide reasons and explanations for their actions meant that consequently they were able to hold responsibility for these actions The HCPs were asked to justify the deasions they made m both data sets Four subunits of responses emerged The first refers to medical knowledge as a source of justification The second refers to the value systems espoused by the HCPs The third refers to the HCPs' expenence, which can be seen as an integration of knowledge generated through both expenential cind cognitive elements (The former refers to HCPs' daily concrete interaction with the patients and the latter refers to their ability to locate events from the past and to carry their suggestions mto a defensible and justifiable argument) The last subunit refers to whether the HCPs were capable of justifying the proposed action m other words, whether they were able to apply their cognitive and affective skills to a process of justification and explanation From the HCPs' own expenence, it emerged that four nurses referred to their own value systems, another four nurses referred to their own expenence and one nurse referred to the consequences of the action On the other hand, within the doctors' group, two doctors referred to the medical knowledge, five doctors to their belief systems and two were not able to articulate a justification for the decision However, in response to the prompted case, two nurses made reference to medical knowledge, four nurses referred to their value systems, one nurse to expenence and one nurse to the consequences of the action Within the doctors' group, four doctors made reference to the medical 135

R Grundstem-Amado

knowledge, three to their belief systems and two were not able to provide justification for the deasion Accordmgly, differences between past expenence reports and responses to the prompted case emerged In their past expenence, nurses tended to depend equally on their belief systems and their professional expenence as sources of justification, whereas doctors tended to depend most on their value systems and least on medical knowledge In contrast, responses to the prompted case revealed different emphases in the justification process The doctors relied most on medical knowledge and least on their own value systems, in contrast, the nurses leaned most on their value systems and least on medical knowledge In refemng to the value system as a source of justification, it seems that the nurses were rather consistent m their behaviour, whde the doctors were less consistent The nurses' ability to approach the problem and justify the solution can be groimded m their feminist values and from their fundamental need for attachment Ferguson asserts that connectedness with others is the core element of women's survival and development as human beings (Ferguson 1984) Accordingly, the nurses' conception and justification of moral problems are concerned with mdudmg the diverse needs and wishes of the patients, rather than with considenng tind refemng to other opposmg claims, such as consequences or medical knowledge The doctors had to justify their actions on the basis of their professioniil commitment and obligation to use their best judgement for the best mterests of the patient Best judgement is pnmanly rooted in the doctors' professional knowledge and secondanly m their morail behefs Doctors tend to judge themselves by standards of professional competency and medical achievement For example, Dr (H) comments 'as long as the medical expert opmion is there to back you up, the court cannot do anythmg' Accordingly, Doctor (H) sought a factual basis in order to apply a 'defensive medicme' m which he would be able to justify his final decision Another mteresting finding was that in relating their past expenence the nurses did not refer to medical knowledge as a source of justification However, in response to the hypothetical case, two nurses made reference to medical knowledge This may be explained as a result of utilizing the specific mterview method, which contnbuted to more mtegration of the mmd and enabled the participants to consider and resolve the conflict between their deep convictions and the objective medical arcumstances General picture

The general picture was that m the process of justification the HCPs were able to provide explanations based on 136

reasonable inferences related to their beliefs, expenence and medical knowledge However, they did not reflect upon or consult the whole process of deasion making Even though the HCPs were able to report the reasons for their choices, they were unaware of the process itself These findmgs support Nisbett & Wilson's (1977) claim that, m attempts to eliat verbal reports from mdividuals on their mental processes, the mdividuals offen are not aware of their own mental processes, particularly those which lead to judgements CONCLUSIONS The findings suggest the need for a further study in which both genders are represented m both professional groups Additional types and cimounts of such data are needed to elaborate a theory of ethical deasion makmg used by nurses and doctors An expansion m the numbers of participants may broaden the concepts being explored in this study, and might suggest new directions m the understanding of the underlying processes of HCPs' ethical behaviour It seems that individual HCPs ascnbe different meanings to the notion of care giving Each mdividual HCP cames his/her own unique subjective world view and personal expenence, which ultimately affect his or herfinalcourse of action Nurses and doctors, as found m this study, act out of different values, motivations and expectations which consequently result m a communication gap These two groups view the patient's best interests from two different perspectives Nurses are motivated in their ethical behaviour by the fundamental value of 'canng' which entails responsiveness and sensitivity to the patient wishes Canng is seen as a commitment to a particular end (Gadow 1985) In contrast, the doctors value above all the patients' nghts and the scientific approach that implies a major concem with disease and its cure Collective moral sphere Since doctors and nurses are working in a collective moral sphere, and are dnven by shared fundamental responsibility (i e the promotion of the well-being of the patient), it is suggested that there is a need for the development of a new foimdation based on common professional attnbutes shared by the two groups Both groups seek a common ground that provides a source of unification of ideas, and that can serve as a new framework from which they can solve common ethical problems and justify their solutions

Bhtcal decision-making processes

It IS suggested that the professional authonties (e g the college of nurses and the college of physiaans and surgeons) need to work together to address the issue of the construction of a new framework to which both groups are committed and which is consistent with both the nurses' and doctors' ethical codes The researcher would argue that the basic value of 'canng' can serve as a core concept and a common ground that substiintiates both nurses' and doctors' professional practice Canng is rooted in a sound and well-informed decisionmakmg process Canng for the patient is not a distinct feminine value that is exclusively adopted by nurses It is a fundamental attnbute of any medical discourse To care for the patient is to seek out a connection with the patient's values, religious and spmtual convictions, it is to understand the patient's fears, hopes, expectations and historical expenence To care for the patient is to be responsible for the choices that are made and their outcomes To care is to be alert to the fact that the application of any medical intervention must be done with an awareness of its possible effects More importantly, to care is to understand implicitly that the choices we make as individual decision makers spnng from our past events, values, interests, motivations and expectations, and that their consequences create a united narrative for both professionals and patients

Gilhgan C (1982) In A Different Voice Harvard University Press, Cambridge, Massachusetts Grundstein-Amado R (1990) Ethical deasion makmg processes in the health care system Unpublished PhD thesis University of Toronto, Toronto Grundstem-Amado R (1991) An integrative model of climcal ethical deasion making Theoretical Medicine, 12,153—170 Hagell EI (1989) Nursing knowledge women's knowledge A sociological perspective journal of Advanced Nursing 14(3), 226-233 Jameton A (1984) Nursing Practice The Ethical Issues PrenticeHall, Engelwood Cliffs, New Jersey Nisbett R & Wilson T (1977) Telling more than we can know verbal reports on mental processes Psychological Review 84, 231-259 Nodding N (1984) Canng a Feminine Approach to Ethics and Moral Education Califomia Press, Berkeley

APPENDIX. HYPOTHETICAL CASE

Miss J presented several months ago with progressive neurological deficits It was clear that she was suffenng from progressive multifocal leukoencephalopathy, an inevitably fatal disease of the central nervous system Dunng vanous diagnostic studies, it also became dear that she was suffenng from Hodghn's disease All of this was explained to the patient, who was awake and reasonably onented and who usually displayed good short-term memory The References patient and her family are aware of the fact that there has Beauchamp T &ChildressJ {19&i) Principles of Bwmedical Ethics been significant progress m the treatment of Hodgbn's Oxford University Press, New York disease by use of a four-drug combination chemotherapy Beck C (1984) The nature of values and lmpbcahons for value known as MOPP The patient and her family wish to have education Unpublished paper Department of History and her Hodgkin's disease treated The physicians are reluctant Philosophy, University of Toronto to do so, m piirt because the patient is probably going to Brody B (1988) Life and Death Decision hdaking Oxford Univer- die from the leukoencephalopathy before her Hodgkin's sity Press, New York disease produces significant symptoms and in part because Encsson KA & Simon H A (1984) Protocol Analysis, Verbal they believe that the chemotherapy will actually worsen Reports as Data The M I T Press, Cambndge, Massachusetts the patient's immune system and cause more damage than Ferguson K (1984) The Feminist Case Agatnst Bureaucracy Temple good This has been explained to the patient and their University Press, Philadelphia family, but they insist the patient has a curable cancer and Gadow S (1985) Nurse and patient the canng relationship In Canng Curing Copmg Nurse Physician Patient Relationship they want it treated (Bishop A H &ScudderJR eds). University of Alabama Press (Brody 1988, pp 132-133)

137

Differences in ethical decision-making processes among nurses and doctors.

The study reports results of an inquiry into the different patterns of ethical decision making used by doctors and nurses. The findings of the study a...
795KB Sizes 0 Downloads 0 Views