Scand J Caring Sci Vol. 6 , No. 3 1992
Theory and Methods for Research on Ethical Issues in Dementia Care Tore Nilstun
ABSTRACT. Swedish research on ethical issues in dementia care is almost exclusively done by nursing scientists. Many of these studies are rightfully acclaimed as exemplary research. But the strong focusing on the nurse and her relation to the patient tends to bias the ethical issues-the attitudes of other persons involved or affected are also in need of investigation. Further, there is a predilection for content analysis at the expense of causal analysis. In this paper an eclectic approach to the study of ethical issues in dementia care is advocated. More interdisciplinary communication and co-operation is also needed-especially between nursing scientists and moral philosophers. To facilitate such communication and co-operation a model for analysis of ethical issues is presented and discussed. To illustrate my ideas I use three articles by researchers from the department of advanced nursing in Umel: Ekman & Norberg ( 1988), Norberg & Asplund (1990) and Akerlund & Norberg (1989-90). Key worris: Causal analysis, content analysis, methods, nursing ethics.
IDIOGRAPHIC AND NOMOTHETIC SCIENCES Within the scientific community there are different conceptions of what constitutes good research. These are, after Kuhn (1970/1962), called “paradigms”. Paradigms have their roots in a variety of different scientific traditions. However, two such traditions are of special interest in research on ethical issues in dementia care. The first is inspired by the idiographic sciences and the second by the nomothetic sciences. The idiographic sciences focus their interest on what is concrete, individual or unique. Typical examples of research in this tradition are found in history and cultural anthropology. The nomothetic sciences focus their interest on what is abstract or general, they deal with universal statments or laws. Typical examples of research in this tradition are found in mathematics and logic (formal nomothetic sciences) and physics, chemistry and biology (empirical nomothetic sciences).
Within these two traditions there are some characteristic differences as to conceptions of what constitutes good research. Scientists socialized in the nomothetic tradition prefer preactive designs (i.e. the study should be planned in detail in advance), experimental designs (i.e. the units investigated should, if possible, be randomized in experimental and control groups) and hypothetico-deductive designs (i.e. the study should aim at testing hypotheses and their implications). Their view of reality is atomistic (i.e. different types of phenomena can be studied independently of each other and their context) and causal relations between phenomena are discovered by using quantitiative data and statistical analysis. Eloquent advocates of this tradition are Campbell & Stanley (1966).
TORE NILSTUN, Phd. Department of Philosophy, University of Lund, Sweden. Submitted for publication April 5, 1991, accepted May 24, 1991. Correspondence: T. Nilstun, Shgarevagen 4 C, S-223 71 Lund, Sweden. Scand J Caring Sci
174
T. Nilstun
Scientists inspired by the idiographic tradition often prefer interactive designs (i.e. the study should not be planned in advance-at least not in detail), naturalistic designs (i.e. the units studied and their environment should, if possible, not be manipulated) and inductive-explorative designs (i.e. the hypotheses should not be formulated in advance, but developed in the course of the study). Their view of reality is holistic (i.e. a phenomenon is to be understood in its context) and the concept of 'significance' is of special importance. The significance of experiences is studied by collecting and analyzing qualitative data. A renowned spokesman for this tradition is Patton (1987). Per se there is nothing wrong with any of these ideals of science. Both are legitimate ways of doing research. But the attitudes of enthusiastic adherents to one or other of these traditions sometimes create problems. Many students are exclusively trained in the nomothetic tradition. They are strongly disposed to be prejudiced against the idiographic tradition. In my experience, this is true for many researchers in medicine. Those students who are fully trained in the idiographic tradition seem to be almost equally prejudiced against the nomothetic tradition. In my experience, this is not uncommon among nursing scientists. Two examples may illustrate the types of arguments sometimes used in the controversy between the idiographic and the nomothetic traditions: A . . . precondition for science is the belief that all facts, whether about the external world or man's thought and desires, are causally dependent on physical processes and are reducible to such processes, what the philosophers call materialism. (Sjostand 1979, p. 77-my translation) . . . the psychosomatic disorders are not "caused" by the traditional mind-body interaction because there are no dichotomy between the physical and [the] psychological . . . The so-called hermeneuticphenomenological paradigm incorporates not only the possible somatic, psychological or social pathogenetic elements but also holistic concepts. The signification of observed phenomena is the basis for understanding the disorder. (Svensson 1983, p. 18)
The speculative nature of such statements justify a warning to nursing scientists and medical scientists. Both of these traditions have strengths and weaknesses. An eclectic approach is therefore justified, i.e. one should select from
the various traditions those theories and research methods that are relevant to the purpose in question.
AN EXAMPLE One such eclectic approach may be illustrated by the works of Ekman & Norberg (1988), Norberg & Asplund ( 1990) and Akerlund & Norberg ( 1989-90). Though they are highly influenced by the idiographic tradition they do not exclude all items from the nomothetic tradition. In their semistructured or focused interviews with caregivers they utilize items from both. However, at least two items from the nomothetic tradition are missing: causal analysis and hypothetico-deductive design. These studies focus on the meaning of caring, feelings towards spoon-feeding and respect for autonomy of demented patients. The design used is almost exclusively inductive-explorative. The variety of items utilized in the studies by Norberg and her associates are summed up in Fig. 1. The questions asked by Norberg and her associates are important and the methods used appropriate. But if research on ethical issues in dementia care are not only meant to be academic, there are further questions to be answered (cf. Ekman & Norberg 1988). These are practical questions about the possiblility
NOMOTHETIC
IDIOGRAPHIC
Design preactive" experimental. hypotheticodeductive Causality Quantitative data' analysis' Atomism'
Design interactive* naturalistic" inductiveexplorative" Significance** Qualitative data" analysis" Holism"
Fig. 1. Double asterisk (**) indicaies that the studies by Asplund, Ekman, Norberg and Akerlund are dominated by that item; single asterisk (*) indicates some element of that item; and no asterick indicates absence of that item. Scand J Caring Sci
Research on ethics and dementia care
and legitimacy of influencing caregiver’s moral attitudes. To answer questions about the legitimacy of influencing attitudes requires ethical assessment of caregiver’s attitudes. This would, in my opinion, be enhanced if nursing scientists and moral philosophers worked together, thereby expanding the tradition of interdisciplinarity in gerontology (Sarvimaki 1989). To answer questions about the possibility of influencing attitudes requires causal analysis. In my opinion, such analysis requires hypothetico-deductive design (Nilstun & Hermeren 1986) and therefore would benefit from increased communication and cooperation between scientists of idiographic and nomothetic orientation.
A MODEL FOR ANALYSIS OF ETHICAL ISSUES To facilitate such communication and co-operation a common frame of reference or model is needed. In this section I am going to present one such model. It combines ideas from Hermeren (1986, pp. 69-89) and Francoeur (1983, pp. 127-37). The basic idea of the model is illustrated in Fig. 2. The model consists of two dimensions. The first dimension specifies the (groups of) persons involved in or affected by the situation to be analyzed e.g. the feeding of demented patients. The second dimension specifies the revelant ethical principles, i.e. those principles which give rise to the moral obligations and rights of these persons. This model can be used in two different ways-as a checklist for identification of ethical issues in a problem situation (e.g. in feeding of demented patients) and as a tool for ethical assessment of alternative actions (e.g. whether to spoon-feed, to use a naso-gastric tube or not to feed the demented patient at all). In order to show the utility of this model as a checklist I
I Persons
involved or affected
I
I
Relevant ethical DrinciCiples A
0
C
115
shall apply it to the problem situations studied by Norberg and her associates. (The model is used for ethical assessment in Nilstun 1990 and 1991.) The first task in applying the model is to identify the persons involved in or affected by the situation. In the three articles by Norberg and her associates the persons in focus are experienced caregivers and their patients. Relatives and members of the nursing staff are also referred to. Not mentioned, but possibly relevant, are the chief physician and other patients. The second task is to identify the relevant ethical principles. To formulate such principles is not a preresquisite. Basic values work equally well. The principles (or values) mentioned in their studies are autonomy (the patient’s right to decide for himself what to do, and the caregiver’s obligation to ask him for permission to do things for or with him); paternalism or beneficence (the caregiver’s acting for the benefit of the patient without his consent or even against it). In my opinion a more comprehensive ethical analysis of the problem situation requires that the principle of justice should be considered (nurses also have responsibilities towards other patients) and possibly also the principle of sancity of life. The two dimensions, containing the persons involved or affected and the relevant ethical principles, are related to each other as shown in Fig. 3. I know that Norberg and her associates are fully aware of all the persons and principles mentioned in this matrix table. As a matter of
~ ~ ~ m w ~ n c i p t e a
Persons involved or
Autonomy Bemlim
Jwlice
Sanctity
Caregivers Patients
I
Chief phybician
I
I I
I
I
I I
D
Group 1 Group 2 Group 3
Fig. 2 . A model for identlfication and analysis of ethical issues.
Fig. 3 . The model for identification of ethical issues applitd to the studies by Asplund, Ekman, Norberg and Akerlund. “0”denotes an obligation of the person in question, while “R” denotes a right. Double asterisk (**) indicates that the issue is discussed more fully; single asterisk (*) that the issue is only mentioned; and no asterisk that the issue is omitted. Scand J Caring Sci
176
T. Nilstun
fact the persons involved or affected and the ethical principles indicated are all taken from an article by Jansson & Norberg (1989). This means that I am not accusing them of ignornace. My criticism has to do with the many empty cells in the model. Not that all the cells should be given equal attention in every study. For practical reasons this is not feasible. But the concentration on a limited set of cells should be justified, and possible implications for the ethical analysis discussed. This is important because the purpose of the studies by Norberg and her associates is not purely descriptive. They also give ethical recommendations (cf. Ekman & Norberg 1988). However, this criticism seems to presuppose a particular interpretation of ethical judgements and their justification. There are two possibilities. The first is that ethical judgements are neither true nor false. Personally I am inclined to accept this position and agree with Bertrand Russell (1979/1925, p. 48) when he writes that
. . . there is no outside standard to show that our valuation is wrong. We are ourselves the ultimate and irrefutable arbiter of values, and in the world of value Nature is only a part. Thus in this world we are greater than Nature. In the world of value, Nature in itself is neutral, neither good nor bad, deserving of neither admiration nor censure. It is we who create value and our desires which confer value. I also agree with Tranary (1990, p. 24) when he writes that the “force and acceptability of [medical] ethics derives from the ordinary and shared morality of the culture or society which medicine has to serve”. The second possibility is that ethcial judgements are either true or false (and it is, at least in some situations, possible to know whether a particular judgement is true or false). Norberg is inclined to accept what is called “an ontological ethical model” (personal communication, cf, also Bexell et al. 1985). According to this model “the mere existence of the helpless patient makes it necessary for the caregiver to answer the ethical demand that the patient presents” (Norberg & Asplund 1990). This means that basic ethical principles or values sometimes can be discovered by idiographic studies of human relations. If this theory is correct the narrow focus on the attitudes of caregivers to their patients
is justified. The problem is, however, that there seems to be no way to decide whether ethical judgements can be true or false. This question has been discussed for nearly a century, and there still is no agreement as to the type of empirical data needed for verification or falsification. For the time being it is therefore prudent to work with explicitly stated value premises when assessing moral attitudes. This means that an important task for researchers on ethical issues in dementia care is to discuss the conditions that such value premises should fulfill (cf. Myrdal 1944, Appendix 2, sec. 2).
SUMMARY In this paper I have distinguished between two research traditions, the idiographic and the nomothetic. These are characterized by different conceptions of how research should be done. It is my impression that medical scientists are more prone to the nomothetic tradition and less to the idiographic tradition. They have a predilection for causal analysis at the expense of content analysis. For many nursing scientists it seems to be the other way round. An eclectic approach to the study of ethical issues in dementia care is advocated. Though content analysis is both important and appropriate it is desirable that it should be complemented with causal analysis. The possibility and legitimacy of influencing moral attitudes should be investigated. To assess such attitudes value premises are needed. These should be formulated and discussed. All this requires communication and co-operation not only between adherents to the idiographic and the nomothetic traditions but also between nursing scientists and moral philosophers. I believe that the model presented could facilitate such communication and co-operation.
ACKNOWLEDGEMENT This article is a somewhat modified version of a paper I read at a workshop following the first Nordic conference on dementia care in Umed, February 1991. I would like to thank Professor Astrid Norberg, Umed University and Assistant Professor Ingrid Petersson, Lund University, for their comments on an earlier draft of this paper. Scand J Caring Sci
Research on ethics and dementia care
REFERENCES Bexell, G., Norberg, A. & Norberg, B. 1985. Ethical conflicts in long-term care of aged patients: An ontological model of the care situation. Ethics & Medicine, 1( 3), 44-6. Campbell, D. T. & Stanley, J. C. 1966. Experimental and quasi-experimental designs for research. Rand McNally college publishing company, Chicago. Ekman, S. L. & Norberg, A. 1988. The autonomy of demented patients: interviews with caregivers. Journal of Medical Ethics, 14, 184-7. Francoeur, R. T. 1983. Biomedical ethics. A guide to decision making. John Wiley & Sons, New York. Hermeren, G. 1986. Kunskapens pris. Forskningsetiska problem och principer i humaniora och samhallsvetenskap. Forskningsridens forlagstjanst, Stockholm. Jansson, L. & Norberg, A. 1989. Ethical reasoning concerning the feeding of terminally ill cancer patients. Interviews with registered nurses experienced in the care of cancer patients. Cancer Nursing, 12(6), 352-8. Kuhn, T. 196211970. The structure of scientiJic revolutions. University of Chicago Press, Chicago. Myrdal, G. 1944. An American dilemma. Harper & Brother, New York. Nilstun, T. 1990. Public health meaures with HIV infection: A model for identification and analysis of ethical conflicts. In P. Allebeck & B. Jansson (eds) Ethics in medicine. Raven Press, New York, pp. 203-13. Nilstun, T. 1991. Medicin och moral. En bok om
177
forskningsetik -med exempel frrin forskningen kring HIV och aids. Studentlitteratur, Lund. Nilstun, T. & Hermeren, G. 1984. Utvardereringsforskning och rattsliga reformer. Analys av orsaker och effekter. Studentlitteratur, Lund. Norberg, A. & Asplund, K. 1990. Caregivers’ experience of caring for severely demented patients. Western Journal of Nursing Research, 12( l), 7584. Patton, M. Q. 1987. How to use qualitative methods in evaluation. Sage publications, Newbury Park, Beverly Hills, London, New Delhi. Russell, B. 1979/1925. What I believe. (Reprinted in P. Edwards (ed.) Why I am not a Christian. Unwin Paperbacks, London, pp. 43-69.) Sarvimaki, A. 1989. Aldersforskning som interdisciplinart kunskapsomride. Gerontologia, 3(4), 292-7. Sjostrand, T. 1979. Medicinsk vetenskap. Historik, teori och tillampning. Natur och Kultur, Stockholm. Svensson, J. C. 1983. Early stages of essential hypertension in a psychosomatic perspective -epidemio logical, clinical, psychophysiological and psychological studies of 18-year-old men. Department of psychology, Stockholm. Tranray, K. E. 1990. The roots of medical ethics in a shared morality. In P. Allebeck & B. Jansson (eds) Ethics in medicine. Raven Press, New York, pp. 23-31. Akerlund, B. M. & Norberg, A. 1989-90. Powerlessness in terminal care of demented patients: an explorative study. Omega, 21( l), 15-9.
Scand J Caring Sci
Theory and Methods for Research on Ethical Issues in Dementia Care Tore Nilstun
ABSTRACT. Swedish research on ethical issues in dementia care is almost exclusively done by nursing scientists. Many of these studies are rightfully acclaimed as exemplary research. But the strong focusing on the nurse and her relation to the patient tends to bias the ethical issues-the attitudes of other persons involved or affected are also in need of investigation. Further, there is a predilection for content analysis at the expense of causal analysis. In this paper an eclectic approach to the study of ethical issues in dementia care is advocated. More interdisciplinary communication and co-operation is also needed-especially between nursing scientists and moral philosophers. To facilitate such communication and co-operation a model for analysis of ethical issues is presented and discussed. To illustrate my ideas I use three articles by researchers from the department of advanced nursing in Umel: Ekman & Norberg ( 1988), Norberg & Asplund (1990) and Akerlund & Norberg (1989-90). Key worris: Causal analysis, content analysis, methods, nursing ethics.
IDIOGRAPHIC AND NOMOTHETIC SCIENCES Within the scientific community there are different conceptions of what constitutes good research. These are, after Kuhn (1970/1962), called “paradigms”. Paradigms have their roots in a variety of different scientific traditions. However, two such traditions are of special interest in research on ethical issues in dementia care. The first is inspired by the idiographic sciences and the second by the nomothetic sciences. The idiographic sciences focus their interest on what is concrete, individual or unique. Typical examples of research in this tradition are found in history and cultural anthropology. The nomothetic sciences focus their interest on what is abstract or general, they deal with universal statments or laws. Typical examples of research in this tradition are found in mathematics and logic (formal nomothetic sciences) and physics, chemistry and biology (empirical nomothetic sciences).
Within these two traditions there are some characteristic differences as to conceptions of what constitutes good research. Scientists socialized in the nomothetic tradition prefer preactive designs (i.e. the study should be planned in detail in advance), experimental designs (i.e. the units investigated should, if possible, be randomized in experimental and control groups) and hypothetico-deductive designs (i.e. the study should aim at testing hypotheses and their implications). Their view of reality is atomistic (i.e. different types of phenomena can be studied independently of each other and their context) and causal relations between phenomena are discovered by using quantitiative data and statistical analysis. Eloquent advocates of this tradition are Campbell & Stanley (1966).
TORE NILSTUN, Phd. Department of Philosophy, University of Lund, Sweden. Submitted for publication April 5, 1991, accepted May 24, 1991. Correspondence: T. Nilstun, Shgarevagen 4 C, S-223 71 Lund, Sweden. Scand J Caring Sci
174
T. Nilstun
Scientists inspired by the idiographic tradition often prefer interactive designs (i.e. the study should not be planned in advance-at least not in detail), naturalistic designs (i.e. the units studied and their environment should, if possible, not be manipulated) and inductive-explorative designs (i.e. the hypotheses should not be formulated in advance, but developed in the course of the study). Their view of reality is holistic (i.e. a phenomenon is to be understood in its context) and the concept of 'significance' is of special importance. The significance of experiences is studied by collecting and analyzing qualitative data. A renowned spokesman for this tradition is Patton (1987). Per se there is nothing wrong with any of these ideals of science. Both are legitimate ways of doing research. But the attitudes of enthusiastic adherents to one or other of these traditions sometimes create problems. Many students are exclusively trained in the nomothetic tradition. They are strongly disposed to be prejudiced against the idiographic tradition. In my experience, this is true for many researchers in medicine. Those students who are fully trained in the idiographic tradition seem to be almost equally prejudiced against the nomothetic tradition. In my experience, this is not uncommon among nursing scientists. Two examples may illustrate the types of arguments sometimes used in the controversy between the idiographic and the nomothetic traditions: A . . . precondition for science is the belief that all facts, whether about the external world or man's thought and desires, are causally dependent on physical processes and are reducible to such processes, what the philosophers call materialism. (Sjostand 1979, p. 77-my translation) . . . the psychosomatic disorders are not "caused" by the traditional mind-body interaction because there are no dichotomy between the physical and [the] psychological . . . The so-called hermeneuticphenomenological paradigm incorporates not only the possible somatic, psychological or social pathogenetic elements but also holistic concepts. The signification of observed phenomena is the basis for understanding the disorder. (Svensson 1983, p. 18)
The speculative nature of such statements justify a warning to nursing scientists and medical scientists. Both of these traditions have strengths and weaknesses. An eclectic approach is therefore justified, i.e. one should select from
the various traditions those theories and research methods that are relevant to the purpose in question.
AN EXAMPLE One such eclectic approach may be illustrated by the works of Ekman & Norberg (1988), Norberg & Asplund ( 1990) and Akerlund & Norberg ( 1989-90). Though they are highly influenced by the idiographic tradition they do not exclude all items from the nomothetic tradition. In their semistructured or focused interviews with caregivers they utilize items from both. However, at least two items from the nomothetic tradition are missing: causal analysis and hypothetico-deductive design. These studies focus on the meaning of caring, feelings towards spoon-feeding and respect for autonomy of demented patients. The design used is almost exclusively inductive-explorative. The variety of items utilized in the studies by Norberg and her associates are summed up in Fig. 1. The questions asked by Norberg and her associates are important and the methods used appropriate. But if research on ethical issues in dementia care are not only meant to be academic, there are further questions to be answered (cf. Ekman & Norberg 1988). These are practical questions about the possiblility
NOMOTHETIC
IDIOGRAPHIC
Design preactive" experimental. hypotheticodeductive Causality Quantitative data' analysis' Atomism'
Design interactive* naturalistic" inductiveexplorative" Significance** Qualitative data" analysis" Holism"
Fig. 1. Double asterisk (**) indicaies that the studies by Asplund, Ekman, Norberg and Akerlund are dominated by that item; single asterisk (*) indicates some element of that item; and no asterick indicates absence of that item. Scand J Caring Sci
Research on ethics and dementia care
and legitimacy of influencing caregiver’s moral attitudes. To answer questions about the legitimacy of influencing attitudes requires ethical assessment of caregiver’s attitudes. This would, in my opinion, be enhanced if nursing scientists and moral philosophers worked together, thereby expanding the tradition of interdisciplinarity in gerontology (Sarvimaki 1989). To answer questions about the possibility of influencing attitudes requires causal analysis. In my opinion, such analysis requires hypothetico-deductive design (Nilstun & Hermeren 1986) and therefore would benefit from increased communication and cooperation between scientists of idiographic and nomothetic orientation.
A MODEL FOR ANALYSIS OF ETHICAL ISSUES To facilitate such communication and co-operation a common frame of reference or model is needed. In this section I am going to present one such model. It combines ideas from Hermeren (1986, pp. 69-89) and Francoeur (1983, pp. 127-37). The basic idea of the model is illustrated in Fig. 2. The model consists of two dimensions. The first dimension specifies the (groups of) persons involved in or affected by the situation to be analyzed e.g. the feeding of demented patients. The second dimension specifies the revelant ethical principles, i.e. those principles which give rise to the moral obligations and rights of these persons. This model can be used in two different ways-as a checklist for identification of ethical issues in a problem situation (e.g. in feeding of demented patients) and as a tool for ethical assessment of alternative actions (e.g. whether to spoon-feed, to use a naso-gastric tube or not to feed the demented patient at all). In order to show the utility of this model as a checklist I
I Persons
involved or affected
I
I
Relevant ethical DrinciCiples A
0
C
115
shall apply it to the problem situations studied by Norberg and her associates. (The model is used for ethical assessment in Nilstun 1990 and 1991.) The first task in applying the model is to identify the persons involved in or affected by the situation. In the three articles by Norberg and her associates the persons in focus are experienced caregivers and their patients. Relatives and members of the nursing staff are also referred to. Not mentioned, but possibly relevant, are the chief physician and other patients. The second task is to identify the relevant ethical principles. To formulate such principles is not a preresquisite. Basic values work equally well. The principles (or values) mentioned in their studies are autonomy (the patient’s right to decide for himself what to do, and the caregiver’s obligation to ask him for permission to do things for or with him); paternalism or beneficence (the caregiver’s acting for the benefit of the patient without his consent or even against it). In my opinion a more comprehensive ethical analysis of the problem situation requires that the principle of justice should be considered (nurses also have responsibilities towards other patients) and possibly also the principle of sancity of life. The two dimensions, containing the persons involved or affected and the relevant ethical principles, are related to each other as shown in Fig. 3. I know that Norberg and her associates are fully aware of all the persons and principles mentioned in this matrix table. As a matter of
~ ~ ~ m w ~ n c i p t e a
Persons involved or
Autonomy Bemlim
Jwlice
Sanctity
Caregivers Patients
I
Chief phybician
I
I I
I
I
I I
D
Group 1 Group 2 Group 3
Fig. 2 . A model for identlfication and analysis of ethical issues.
Fig. 3 . The model for identification of ethical issues applitd to the studies by Asplund, Ekman, Norberg and Akerlund. “0”denotes an obligation of the person in question, while “R” denotes a right. Double asterisk (**) indicates that the issue is discussed more fully; single asterisk (*) that the issue is only mentioned; and no asterisk that the issue is omitted. Scand J Caring Sci
176
T. Nilstun
fact the persons involved or affected and the ethical principles indicated are all taken from an article by Jansson & Norberg (1989). This means that I am not accusing them of ignornace. My criticism has to do with the many empty cells in the model. Not that all the cells should be given equal attention in every study. For practical reasons this is not feasible. But the concentration on a limited set of cells should be justified, and possible implications for the ethical analysis discussed. This is important because the purpose of the studies by Norberg and her associates is not purely descriptive. They also give ethical recommendations (cf. Ekman & Norberg 1988). However, this criticism seems to presuppose a particular interpretation of ethical judgements and their justification. There are two possibilities. The first is that ethical judgements are neither true nor false. Personally I am inclined to accept this position and agree with Bertrand Russell (1979/1925, p. 48) when he writes that
. . . there is no outside standard to show that our valuation is wrong. We are ourselves the ultimate and irrefutable arbiter of values, and in the world of value Nature is only a part. Thus in this world we are greater than Nature. In the world of value, Nature in itself is neutral, neither good nor bad, deserving of neither admiration nor censure. It is we who create value and our desires which confer value. I also agree with Tranary (1990, p. 24) when he writes that the “force and acceptability of [medical] ethics derives from the ordinary and shared morality of the culture or society which medicine has to serve”. The second possibility is that ethcial judgements are either true or false (and it is, at least in some situations, possible to know whether a particular judgement is true or false). Norberg is inclined to accept what is called “an ontological ethical model” (personal communication, cf, also Bexell et al. 1985). According to this model “the mere existence of the helpless patient makes it necessary for the caregiver to answer the ethical demand that the patient presents” (Norberg & Asplund 1990). This means that basic ethical principles or values sometimes can be discovered by idiographic studies of human relations. If this theory is correct the narrow focus on the attitudes of caregivers to their patients
is justified. The problem is, however, that there seems to be no way to decide whether ethical judgements can be true or false. This question has been discussed for nearly a century, and there still is no agreement as to the type of empirical data needed for verification or falsification. For the time being it is therefore prudent to work with explicitly stated value premises when assessing moral attitudes. This means that an important task for researchers on ethical issues in dementia care is to discuss the conditions that such value premises should fulfill (cf. Myrdal 1944, Appendix 2, sec. 2).
SUMMARY In this paper I have distinguished between two research traditions, the idiographic and the nomothetic. These are characterized by different conceptions of how research should be done. It is my impression that medical scientists are more prone to the nomothetic tradition and less to the idiographic tradition. They have a predilection for causal analysis at the expense of content analysis. For many nursing scientists it seems to be the other way round. An eclectic approach to the study of ethical issues in dementia care is advocated. Though content analysis is both important and appropriate it is desirable that it should be complemented with causal analysis. The possibility and legitimacy of influencing moral attitudes should be investigated. To assess such attitudes value premises are needed. These should be formulated and discussed. All this requires communication and co-operation not only between adherents to the idiographic and the nomothetic traditions but also between nursing scientists and moral philosophers. I believe that the model presented could facilitate such communication and co-operation.
ACKNOWLEDGEMENT This article is a somewhat modified version of a paper I read at a workshop following the first Nordic conference on dementia care in Umed, February 1991. I would like to thank Professor Astrid Norberg, Umed University and Assistant Professor Ingrid Petersson, Lund University, for their comments on an earlier draft of this paper. Scand J Caring Sci
Research on ethics and dementia care
REFERENCES Bexell, G., Norberg, A. & Norberg, B. 1985. Ethical conflicts in long-term care of aged patients: An ontological model of the care situation. Ethics & Medicine, 1( 3), 44-6. Campbell, D. T. & Stanley, J. C. 1966. Experimental and quasi-experimental designs for research. Rand McNally college publishing company, Chicago. Ekman, S. L. & Norberg, A. 1988. The autonomy of demented patients: interviews with caregivers. Journal of Medical Ethics, 14, 184-7. Francoeur, R. T. 1983. Biomedical ethics. A guide to decision making. John Wiley & Sons, New York. Hermeren, G. 1986. Kunskapens pris. Forskningsetiska problem och principer i humaniora och samhallsvetenskap. Forskningsridens forlagstjanst, Stockholm. Jansson, L. & Norberg, A. 1989. Ethical reasoning concerning the feeding of terminally ill cancer patients. Interviews with registered nurses experienced in the care of cancer patients. Cancer Nursing, 12(6), 352-8. Kuhn, T. 196211970. The structure of scientiJic revolutions. University of Chicago Press, Chicago. Myrdal, G. 1944. An American dilemma. Harper & Brother, New York. Nilstun, T. 1990. Public health meaures with HIV infection: A model for identification and analysis of ethical conflicts. In P. Allebeck & B. Jansson (eds) Ethics in medicine. Raven Press, New York, pp. 203-13. Nilstun, T. 1991. Medicin och moral. En bok om
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