What is nursing ethics? Geoffrey Hunt
This article tries to bring some clarity into the current confusion about the nature of nursing ethics. It distinguishes between the empirical, prescriptive and analytic dimensions of ethics. It then describes six contemporary understandings of the parameters and aims of ethics via six different approaches: moral education, management, professional conduct, bioethics, clinical ethics and political ethics.
INTRODUCTION Project 2000 The requirement made by the statutory bodies that ethics be formally introduced into the nursing and midwifery curriculum provides an opportunity to reorientate practice. Properly designed ethics courses in the Project 2000 curricuta couId go a long way towards liberating nursing from its 19th century shackles and could bring an end to nursing founded on the obedient unthinking repetition of tasks at the behest of doctors. Indeed, ethics could help to lead health care out of its technocratic impasse and point medicine and management in a greener and more democratic direction. This opportunity can only be seized if educators interpret ethics broadly, if they understand it not as ‘just another course’ but as a new paradigm. and if they encourage rather than suppress the criticism and uncertainties that come with it.
Geoffrey Hunt BSc MLitt PhD, Director, National Centre for Nursing 81 Midwifery Ethics, Queen Charlotte’s College, Hammersmith Hospital, Du Cane Road, London WI2 OHS, UK (Requests for offprints to GH) Manuscript accepted 3 June 1992
Many of our contemporary institutions and bureaucracies at-e out of touch with the new social movements, with the fresh awareness of human rights, and with the great cross-fertilising currents of thought in science, technology and the arts. The National Health Service’s clinical and educational management proceeds largely in ignorance of, for example, the Green movement, feminism, the New Physics and the growing demands for constitutional and legal reforms. Ethics could be regarded as an arena f’or the new ideas and initiatives needed to break down the stultifying barriers in our professional hierarchies, to open cross-disciplinary discussion, to question everything from the concepts of ‘patient’, ‘abnormality’ and ‘illness’ to the accountability of doctors, managers and health authorities. There can be no doubt that the Project 2000 report is shaped by certain deep ideals (UKCC 1986). But, as I have argued elsewhere. there is a danger that these ideals will be ignored or impoverished and distorted by a crumbling amalgam of the old health care bureaucracy and the new commercial management (Hunt 1992). If nursing educators do not re-read the report and make it their own, for the benefit of the next generation of nurses, midwives and healthcare clients, then perhaps only paper ideals will remain by the year 2001. 323
324
NURSE EDUCATION
TODAY
Confusion? My experience when addressing meetings at colleges and departments of nursing and midwifery around the country has been that there is considerable confusion about the character of nursing ethics and some apprehension about teaching it. It is variously, and somewhat superficially, treated as a branch of philosophy, sociology of knowledge, moral psychology, bio-ethics, medical ethics, professional conduct, law, moral or education, management personnel counselling. If we are to avoid imposing a jumble of detached abstractions, high-sounding slogans and impossible demands on students then educators must get clear about what is meant, or could be meant, by ‘nursing ethics’. After all, will nursing and midwifery really have made any advances if newly qualified practitioners leave the classroom with ‘utilitarianism’ and ‘autonomy’ on their tongues while their practice goes on exactly as it was before? The educators need to be re-educated. Unfortunately, Project 2000 is being implemented with hardly enough time to give thought to this matter, let alone plan for the qualified teachers and resources required. There is the risk that lecturers who have probably been influenced by one or two bðics texts or a crash course from a bio-ethicist, will relay to students inappropriate or garbled ideas and methods. In this article I will limit myself to clarifying the character of nursing ethics. I will do two things: 1. Distinguish between the empirical, prescriptive and analytic dimensions of ethics. 2. Describe six contemporary understandings of the parameters and aims of ethics.
THREE DIMENSIONS Teachers of ethics should understand that on a traditional epistemological criterion (namely fact, value or logic) there are three different things that could go under the name of ethics. I would recommend that teachers understand
these as three dimensions of the same subject, and all three need attention (Hunt 199la). The three dimensions are: Describing and explaining moral behaviour. For example, ‘Research shows that this group often steals, probably because they are unemployed, and the evidence for this is that . . .’ Judging beliefs and actions and telling people what they ought to do. For example, ‘Stealing is morally wrong, as well as illegal and one should not do it. . .’ Analysing moral ideas, assumptions and justifications. For example, ‘The thief, who is unemployed, justified his action by saying that he was merely taking “what society owed” him, but is this convincing? The idea of a “social debt” means . . .’ Although one should be careful not to confuse these three dimensions it would also be wrong to think they are completely separable. Thus, to give another example, to refuse to describe an act as ‘theft’ (againt prevailing opinion perhaps) may be based on a moral attitude and judgement about certain people and circumstances, and that may in turn be supported by a certain analysis of an ideology of property. If, for the sake ofconvenience, one had to give labels to these three dimensions I think they might be the empirical, the prescriptive and the analytic. Given the contemporary separations between academic disciplines it is easy to see how a teacher with some background in psychology, or perhaps sociology (as is the case with many nursing educators), would tend to go for the empirical dimension and feel more comfortable with describing the facts of moral belief, attitude and behaviour and attempt to explain them in terms of some social-scientific theory. Others, lacking any background in social sciences, would tend to go for what is prescribed in codes of conduct, and Department of Health guidelines, with a smattering of law perhaps. Others with strong moral views, or religious convictions, would see their task (or perhaps their mission) as morally educating students. Many philosophers, entering the health care education environment, but often ignorant of the social realities, would
NURSE EDU(:A’fION
see their task as providing supposedly neutral philosophical theories by which to ‘facilitate rational decision-making’, while other philosophers (such as myself) would eschew this approach in favour of a morally grounded critique of current health care thinking. Let me summarise the content of each dimension.
Prescriptive dimension Here the emphasis is on formulating what one morally, ethically or legally ought or ought not do, on making judgements, approving and disapproving. Sources might be professional codes Department of Health guidelines Health Authority and hospital directives personal moral opinion current moral debates religious tenets the law
policy
There is already a tendency in health care ethics generally to conceive of the teacher’s task as one of prescribing from principles. My view is that while principles certainly have a place in ethics it is a mistake to think that ethics is essentially a body of principles. This mistake occurs because professionals like to believe that all decisions can be made in terms of some established and generally accepted rules and procedures set out by the profession itself. This is quite convincing when one thinks of, for ‘confidentiality’ (although even this example, needs more scrutiny than it has received). Yet a little reflection on morality shows that compassion, patience, understanding, kindness, generosity, human dignity and so on are not principles but the very ground of morality without which even principles would make no sense. It is absurd to imagine that compassion is a principle which can be taught, like respecting confidentiality. Although one may learn the principle of respect for confidentiality, one could never see why this should have any importance if' one were lacking in basic moral attitudes, such as those mentioned.
TODAl
32.5
Empirical dimension Here the emphasis is on the description and explanation of the factsof moral beliefs and behaviour. The social sciences, especially sociology, psychology, political science and history, have various methods, measurement tools and theories to offer in this regard, and there is a wide literature. Students and tutors should be acquainted with the empirical studies of the moral beliefs and behaviour of health care professionals, including doctors and managers, and of clients and their families. There is a great need for empirical studies of the ethics of nursing in relation to power, institutional constraints, professional group dynamics, race and gender, and so on. At the National Centre for Nursing and Midwifery Ethics we are currently engaged in a number of empirical-ethical research projects, including one into patients’ actual beliefs about their treatment in relation to the ‘inf&med consent’ which they are supposed to have already given, and another into the kinds ot disapproval encountered by health carers who ‘blow the whistle’.
Analytic dimension Here the emphasis is on the analysis of theform oj‘ thought adopted in health care. Observation. measurement, experiments, questionnaires, and statistical techniques are not employed in philosophy. Instead, it is about the analysis of concepts and their relations, making explicit underlying assumptions and revealing inconsistencies, incoherence and confusion. Of course, it cannot do this in a vacuum (despite what some philosophers seem to think), and philosophers must have some attitudes and assumptions of their own. It is very much in keeping with the spirit ot Project 2000 to adopt a critical, questioning, probing attitude, even towards the law and professional codes and guidelines. How else are these to be improved and reformed? The prescriptive ethics of the nursing profession is largely about the distinction between malpractice and standard practice, whereas most
326
NURSE EDUCATION
TODAY
really important questions are about the nature of standard practice and the thinking and justifications that go with it. While ‘professional
3. A professional
con-
duct’ is about what is wrong when nurses engage in malpractice accordance
and what is right when they act in
with codes and established
analytic ethics is the examination morally
wrong
established
when
nurses
and standard
way is the frontier
of practice
and the paradigm
of nursing
To give an illustration: assumptions
engaged
practice.
pushed
understanding organism,
cit concern
Thinking
to
be
allegiance
one
theory or argument.
to resolve
the
research
is to understand
to
between
in which the aim the moral
prob-
lar cases. 5. A political ethics approach,
one may analyse
of the political, economic
a
in which the aim
moral issues in the context and institutional
setting in which those issues arise.
of the patient as dys-
model
or caring
abandoned
through
in nursing
in which the aim is what is right/wrong
lems which arise for the clinician in particu-
forward,
with caring for the needy person,
has
is casuistically
with
of them.
on one hand, and an expli-
the biomedical
person
approach, to derive
in which
professionals
5. A clinical ethics approach,
in
the other. One may come to the conclusion either
approach,
bodies require
from philosophical
changed.
in a piece of nursing
biomedical
4. A bio-ethics ‘rationally’
Only in this
discover that there are inconsistencies functional
what disciplinary
practice,
of what may be are
conduct
the aim is to acquaint
this issue cannot
that
for the
(Hunt
1992).
may reveal
consistently
on
that
have
an
to both.
Moral education approach This usually starts quite explicitly moral
or religious
contemporary Catholic
tenets.
example
Church
contraception.
The
from certain most
striking
is the literature
of the
on issues such as abortion The Linacre
and
Centre Report, a jour-
nal produced
by the Linacre
gives a good
idea
of Catholic
Centre,
London
approaches
to
moral issues in health care. It is easy, all too easy, for the teacher
SIX CURRENT APPROACHES
to slip into moralising
in the classroom.
At present,
as far as I have been able to ascertain,
nothing
no nursing
college
moral views, and participating
or department
understands
wrong
with teachers
of ethics There
expressing
is
their
in a debate,
but
ethics in one of the following
ways in a self-con-
they should make it clear that that is what they
scious and consistent
Rather,
are doing.
manner.
to be a case of simply accepting pens to be at hand. even identify
hap-
In many cases one cannot
a single coherent
is lacking is a fulcrum, There
it appears
whatever approach.
What
a solid point of departure.
is often a confusion
of approaches,
some-
Although
theories
Obviously, to assert
it would be quite wrong of a teacher that
Management
probably
come up with a list like this:
1. A moral education
approach,
in which the
aim is to make people morally better. 2. A management approach, in which the aim is to contain institutional, intra-professional and profession-clientele
conflict.
of moral behav-
is no such thing as a moral expert.
circumstances,
no one’s fault.
an
tions or psychological iour, there
because
and is certainly
may become
ethical codes and regula-
times with the bio-ethical approach predominating although, it seems to me, no one can say why it should. All this is not surprising under present If one could distil out distinct approaches on the criterion of an underlying aim one would
a teacher
expert in, for example,
she
knows
she is an expert
is wrong
approach
Signs of this approach ethics teaching,
abortion
in moral matters.
are very widespread
but not in any consistent
in way.
One can recognise it by the language used, which is often a combination of managerial and counselling terms such as ‘coping with stress’, ‘interpersonal communication’, ‘social skills’, ‘emotional ‘information’, ‘assersupport’, tiveness’, ‘relationships’, and ‘decision-making’.
NCKSE EI)U(:?4’I‘IoN
There advice
is often given
a tendency
to take
too far the
‘non-maleficence’
in this quotation:
So sometimes,
especially
‘autonomy’
basic in medical when
the same
ethics
and
(Gillon
worth
This
whether of
improved some
institutional
in some
appropriate
organisational
involved
this which
here,
I think
moral
concepts
I certainly
institution,
with moral
way, either
by
moral
by
degree
those
little
embark
point
acting
roles
or no questioning
patient involved
method
(Ionsen
digm
the
of the
scope
in the
the
but uses are
is little
but have a similaritv claims
consensus
of reasons
and paramoral
there
The approach
to achreve
giving
avoids
theories
supposedly
for disagreement,
of’ the a casuistic
method
from
paradigms
which
the case in hand.
The
the of‘ an
perspective
fashion
These
in
care
and using
decisions
in bio-ethical
usually
goals.
arise
from
has not
resolving
on
et al 19%).
cases.
which
hcuses
(doctor),
to derive
examples
in an
approach. It
which
clinician
principles
on
but rather
out
problems
attempting
that it does not take
recent
nursing.
individual
of tact or
a thorough
cannot
as its starting of people
institution’s
yet reached
needs
it can be shown
manipulaton
be
et al 1983, p 6).
approach
is a fairly
cannot or
a greater
(Thompson
Although critique,
means
cultivating
ingenuity
or personal
communication
are
kind
Clinical ethics approach
asking
Ijustice’
1986).
of moral dilemma regularly occurs, rather than agonising over each dilemma, it may be networks
327
l‘Ol).A\
and
b\
to
IO be able
avoiding
principle5
tar
the \ie~+
XIV
offered.
Professional conduct approach
It is, however,
based
as a decision-making This
emphasises
codes,
a knowledge
Department
regulations,
of
health
Health
authority
cies,
accountability
parts
of the law. A defensive
‘being
covered’
Of course, must but
guidelines and
procedures,
often
be included (Pyne
critical
about
This takes as its point
and regulations
contemporary
somewhere,
manner
and
and
not
of utilitarianism alliance have
been
presents would
and/or
very
Kantian
critical
have
‘reasons’
this or not doing
they such
pretend to employ as ‘utilitarianism’ ethics
model,
medical power more obvious.
in
a critique
this
model,
we must
that (Hunt
for
experts
legitimise
it
danger
accept
who for
1990). Often
metaphysical theories in a prescriptive way
is a narrowed
down
version
of
health
rooted
maintain
in the experiences
morally
system
wrongness, must
for the status
disempowerment
of’
and
amiss with
of thought then
there
of patients
expertise, and
which is the
end up providing
quo, more
OUI-
establishment.
more more
of all of us
when we become old, sick and tired. Paradoxical though it may appear, it is also important to be aware of the moral and political aims assumptions, approach to teaching everything; ideological lives.
alliance
which
of
is that if one has no sense at
care
that ethics
support
between
the
ideology
of the patterns this
and bio-ethical theory is rather Concepts such as ‘beneficence’,
which
a critique and practices,
is something
no awareness
I
1977).
Medical this
in
Elsewhere,
of departure
and nurses.
existing
standpoint rationalism
moral
which
doing
(Glover
of as
and
care systems
and
A basic assumption
technocracy.
philosophers
-
all that there
the philosophical
with medical
health
of the power
them
1992).
adopts
(doctor
with experts
Political ethics approach
Bioethics approach usually
the
poli-
clients
This
of moralit\
still places
philosopher).
this approach.
codes
of judgement
and
relevant
assumption
in the curriculum and
burden
and
hospital and
lies behind
professional
in a flexible
exclusively
of professional
on the notion process
and
methods
ethics.
it too is divided, struggle
over
Ethics
of
one’s
is not above
for it is part of the
the control
of people’s
328
NURSE EDUCATION
TODAY
This approach does not attempt to reduce moral matters to politics. Rather it is premised on an awareness that moral ends so often cannot be achieved because of political, economic and ideological obstacles (Hunt 199 1b).
References Gillon R 1986 Philosophical medical ethics. Wiley, Chichester Glover J 1977 Causing death and saving lives. Penguin, Harmondsworth Hunt G 1991a Multifaceted ethics. Nursing Standard 5 (38) : 46-47
Hunt G 1991b Nursing, patient choice and the NHS reforms. National Board for Northern Ireland, Occasional Paper No. 4, Belfast Hunt G 1992 Taking science too far. Dorset & Salisbury College, Gazette No. 2 Hunt (; 1992 Project 2000 - ethics, ambivalence & ideology. In: Slevin 0, Buckenham M, eds. Project 2000 - the teachers speak. Campion Press, Edinburgh, in press Jonsen A R, Siegler M, Winslade W J 1986 Clinical ethics. Macmillan, New York Pyne R H Professional discipline in nursing, midwifery & health visiting. 2nd ed. Blackwell. Oxford Thompson I E, Ili’elia K M, Boyd K M 1983 Nursing ethics. Churchill Livingstone, London LJKCC 1986 Project 2000: a new preparation for practice. HMSO, London.
This article tries to bring some clarity into the current confusion about the nature of nursing ethics. It distinguishes between the empirical, prescriptive and analytic dimensions of ethics. It then describes six contemporary understandings of the parameters and aims of ethics via six different approaches: moral education, management, professional conduct, bioethics, clinical ethics and political ethics.
INTRODUCTION Project 2000 The requirement made by the statutory bodies that ethics be formally introduced into the nursing and midwifery curriculum provides an opportunity to reorientate practice. Properly designed ethics courses in the Project 2000 curricuta couId go a long way towards liberating nursing from its 19th century shackles and could bring an end to nursing founded on the obedient unthinking repetition of tasks at the behest of doctors. Indeed, ethics could help to lead health care out of its technocratic impasse and point medicine and management in a greener and more democratic direction. This opportunity can only be seized if educators interpret ethics broadly, if they understand it not as ‘just another course’ but as a new paradigm. and if they encourage rather than suppress the criticism and uncertainties that come with it.
Geoffrey Hunt BSc MLitt PhD, Director, National Centre for Nursing 81 Midwifery Ethics, Queen Charlotte’s College, Hammersmith Hospital, Du Cane Road, London WI2 OHS, UK (Requests for offprints to GH) Manuscript accepted 3 June 1992
Many of our contemporary institutions and bureaucracies at-e out of touch with the new social movements, with the fresh awareness of human rights, and with the great cross-fertilising currents of thought in science, technology and the arts. The National Health Service’s clinical and educational management proceeds largely in ignorance of, for example, the Green movement, feminism, the New Physics and the growing demands for constitutional and legal reforms. Ethics could be regarded as an arena f’or the new ideas and initiatives needed to break down the stultifying barriers in our professional hierarchies, to open cross-disciplinary discussion, to question everything from the concepts of ‘patient’, ‘abnormality’ and ‘illness’ to the accountability of doctors, managers and health authorities. There can be no doubt that the Project 2000 report is shaped by certain deep ideals (UKCC 1986). But, as I have argued elsewhere. there is a danger that these ideals will be ignored or impoverished and distorted by a crumbling amalgam of the old health care bureaucracy and the new commercial management (Hunt 1992). If nursing educators do not re-read the report and make it their own, for the benefit of the next generation of nurses, midwives and healthcare clients, then perhaps only paper ideals will remain by the year 2001. 323
324
NURSE EDUCATION
TODAY
Confusion? My experience when addressing meetings at colleges and departments of nursing and midwifery around the country has been that there is considerable confusion about the character of nursing ethics and some apprehension about teaching it. It is variously, and somewhat superficially, treated as a branch of philosophy, sociology of knowledge, moral psychology, bio-ethics, medical ethics, professional conduct, law, moral or education, management personnel counselling. If we are to avoid imposing a jumble of detached abstractions, high-sounding slogans and impossible demands on students then educators must get clear about what is meant, or could be meant, by ‘nursing ethics’. After all, will nursing and midwifery really have made any advances if newly qualified practitioners leave the classroom with ‘utilitarianism’ and ‘autonomy’ on their tongues while their practice goes on exactly as it was before? The educators need to be re-educated. Unfortunately, Project 2000 is being implemented with hardly enough time to give thought to this matter, let alone plan for the qualified teachers and resources required. There is the risk that lecturers who have probably been influenced by one or two bðics texts or a crash course from a bio-ethicist, will relay to students inappropriate or garbled ideas and methods. In this article I will limit myself to clarifying the character of nursing ethics. I will do two things: 1. Distinguish between the empirical, prescriptive and analytic dimensions of ethics. 2. Describe six contemporary understandings of the parameters and aims of ethics.
THREE DIMENSIONS Teachers of ethics should understand that on a traditional epistemological criterion (namely fact, value or logic) there are three different things that could go under the name of ethics. I would recommend that teachers understand
these as three dimensions of the same subject, and all three need attention (Hunt 199la). The three dimensions are: Describing and explaining moral behaviour. For example, ‘Research shows that this group often steals, probably because they are unemployed, and the evidence for this is that . . .’ Judging beliefs and actions and telling people what they ought to do. For example, ‘Stealing is morally wrong, as well as illegal and one should not do it. . .’ Analysing moral ideas, assumptions and justifications. For example, ‘The thief, who is unemployed, justified his action by saying that he was merely taking “what society owed” him, but is this convincing? The idea of a “social debt” means . . .’ Although one should be careful not to confuse these three dimensions it would also be wrong to think they are completely separable. Thus, to give another example, to refuse to describe an act as ‘theft’ (againt prevailing opinion perhaps) may be based on a moral attitude and judgement about certain people and circumstances, and that may in turn be supported by a certain analysis of an ideology of property. If, for the sake ofconvenience, one had to give labels to these three dimensions I think they might be the empirical, the prescriptive and the analytic. Given the contemporary separations between academic disciplines it is easy to see how a teacher with some background in psychology, or perhaps sociology (as is the case with many nursing educators), would tend to go for the empirical dimension and feel more comfortable with describing the facts of moral belief, attitude and behaviour and attempt to explain them in terms of some social-scientific theory. Others, lacking any background in social sciences, would tend to go for what is prescribed in codes of conduct, and Department of Health guidelines, with a smattering of law perhaps. Others with strong moral views, or religious convictions, would see their task (or perhaps their mission) as morally educating students. Many philosophers, entering the health care education environment, but often ignorant of the social realities, would
NURSE EDU(:A’fION
see their task as providing supposedly neutral philosophical theories by which to ‘facilitate rational decision-making’, while other philosophers (such as myself) would eschew this approach in favour of a morally grounded critique of current health care thinking. Let me summarise the content of each dimension.
Prescriptive dimension Here the emphasis is on formulating what one morally, ethically or legally ought or ought not do, on making judgements, approving and disapproving. Sources might be professional codes Department of Health guidelines Health Authority and hospital directives personal moral opinion current moral debates religious tenets the law
policy
There is already a tendency in health care ethics generally to conceive of the teacher’s task as one of prescribing from principles. My view is that while principles certainly have a place in ethics it is a mistake to think that ethics is essentially a body of principles. This mistake occurs because professionals like to believe that all decisions can be made in terms of some established and generally accepted rules and procedures set out by the profession itself. This is quite convincing when one thinks of, for ‘confidentiality’ (although even this example, needs more scrutiny than it has received). Yet a little reflection on morality shows that compassion, patience, understanding, kindness, generosity, human dignity and so on are not principles but the very ground of morality without which even principles would make no sense. It is absurd to imagine that compassion is a principle which can be taught, like respecting confidentiality. Although one may learn the principle of respect for confidentiality, one could never see why this should have any importance if' one were lacking in basic moral attitudes, such as those mentioned.
TODAl
32.5
Empirical dimension Here the emphasis is on the description and explanation of the factsof moral beliefs and behaviour. The social sciences, especially sociology, psychology, political science and history, have various methods, measurement tools and theories to offer in this regard, and there is a wide literature. Students and tutors should be acquainted with the empirical studies of the moral beliefs and behaviour of health care professionals, including doctors and managers, and of clients and their families. There is a great need for empirical studies of the ethics of nursing in relation to power, institutional constraints, professional group dynamics, race and gender, and so on. At the National Centre for Nursing and Midwifery Ethics we are currently engaged in a number of empirical-ethical research projects, including one into patients’ actual beliefs about their treatment in relation to the ‘inf&med consent’ which they are supposed to have already given, and another into the kinds ot disapproval encountered by health carers who ‘blow the whistle’.
Analytic dimension Here the emphasis is on the analysis of theform oj‘ thought adopted in health care. Observation. measurement, experiments, questionnaires, and statistical techniques are not employed in philosophy. Instead, it is about the analysis of concepts and their relations, making explicit underlying assumptions and revealing inconsistencies, incoherence and confusion. Of course, it cannot do this in a vacuum (despite what some philosophers seem to think), and philosophers must have some attitudes and assumptions of their own. It is very much in keeping with the spirit ot Project 2000 to adopt a critical, questioning, probing attitude, even towards the law and professional codes and guidelines. How else are these to be improved and reformed? The prescriptive ethics of the nursing profession is largely about the distinction between malpractice and standard practice, whereas most
326
NURSE EDUCATION
TODAY
really important questions are about the nature of standard practice and the thinking and justifications that go with it. While ‘professional
3. A professional
con-
duct’ is about what is wrong when nurses engage in malpractice accordance
and what is right when they act in
with codes and established
analytic ethics is the examination morally
wrong
established
when
nurses
and standard
way is the frontier
of practice
and the paradigm
of nursing
To give an illustration: assumptions
engaged
practice.
pushed
understanding organism,
cit concern
Thinking
to
be
allegiance
one
theory or argument.
to resolve
the
research
is to understand
to
between
in which the aim the moral
prob-
lar cases. 5. A political ethics approach,
one may analyse
of the political, economic
a
in which the aim
moral issues in the context and institutional
setting in which those issues arise.
of the patient as dys-
model
or caring
abandoned
through
in nursing
in which the aim is what is right/wrong
lems which arise for the clinician in particu-
forward,
with caring for the needy person,
has
is casuistically
with
of them.
on one hand, and an expli-
the biomedical
person
approach, to derive
in which
professionals
5. A clinical ethics approach,
in
the other. One may come to the conclusion either
approach,
bodies require
from philosophical
changed.
in a piece of nursing
biomedical
4. A bio-ethics ‘rationally’
Only in this
discover that there are inconsistencies functional
what disciplinary
practice,
of what may be are
conduct
the aim is to acquaint
this issue cannot
that
for the
(Hunt
1992).
may reveal
consistently
on
that
have
an
to both.
Moral education approach This usually starts quite explicitly moral
or religious
contemporary Catholic
tenets.
example
Church
contraception.
The
from certain most
striking
is the literature
of the
on issues such as abortion The Linacre
and
Centre Report, a jour-
nal produced
by the Linacre
gives a good
idea
of Catholic
Centre,
London
approaches
to
moral issues in health care. It is easy, all too easy, for the teacher
SIX CURRENT APPROACHES
to slip into moralising
in the classroom.
At present,
as far as I have been able to ascertain,
nothing
no nursing
college
moral views, and participating
or department
understands
wrong
with teachers
of ethics There
expressing
is
their
in a debate,
but
ethics in one of the following
ways in a self-con-
they should make it clear that that is what they
scious and consistent
Rather,
are doing.
manner.
to be a case of simply accepting pens to be at hand. even identify
hap-
In many cases one cannot
a single coherent
is lacking is a fulcrum, There
it appears
whatever approach.
What
a solid point of departure.
is often a confusion
of approaches,
some-
Although
theories
Obviously, to assert
it would be quite wrong of a teacher that
Management
probably
come up with a list like this:
1. A moral education
approach,
in which the
aim is to make people morally better. 2. A management approach, in which the aim is to contain institutional, intra-professional and profession-clientele
conflict.
of moral behav-
is no such thing as a moral expert.
circumstances,
no one’s fault.
an
tions or psychological iour, there
because
and is certainly
may become
ethical codes and regula-
times with the bio-ethical approach predominating although, it seems to me, no one can say why it should. All this is not surprising under present If one could distil out distinct approaches on the criterion of an underlying aim one would
a teacher
expert in, for example,
she
knows
she is an expert
is wrong
approach
Signs of this approach ethics teaching,
abortion
in moral matters.
are very widespread
but not in any consistent
in way.
One can recognise it by the language used, which is often a combination of managerial and counselling terms such as ‘coping with stress’, ‘interpersonal communication’, ‘social skills’, ‘emotional ‘information’, ‘assersupport’, tiveness’, ‘relationships’, and ‘decision-making’.
NCKSE EI)U(:?4’I‘IoN
There advice
is often given
a tendency
to take
too far the
‘non-maleficence’
in this quotation:
So sometimes,
especially
‘autonomy’
basic in medical when
the same
ethics
and
(Gillon
worth
This
whether of
improved some
institutional
in some
appropriate
organisational
involved
this which
here,
I think
moral
concepts
I certainly
institution,
with moral
way, either
by
moral
by
degree
those
little
embark
point
acting
roles
or no questioning
patient involved
method
(Ionsen
digm
the
of the
scope
in the
the
but uses are
is little
but have a similaritv claims
consensus
of reasons
and paramoral
there
The approach
to achreve
giving
avoids
theories
supposedly
for disagreement,
of’ the a casuistic
method
from
paradigms
which
the case in hand.
The
the of‘ an
perspective
fashion
These
in
care
and using
decisions
in bio-ethical
usually
goals.
arise
from
has not
resolving
on
et al 19%).
cases.
which
hcuses
(doctor),
to derive
examples
in an
approach. It
which
clinician
principles
on
but rather
out
problems
attempting
that it does not take
recent
nursing.
individual
of tact or
a thorough
cannot
as its starting of people
institution’s
yet reached
needs
it can be shown
manipulaton
be
et al 1983, p 6).
approach
is a fairly
cannot or
a greater
(Thompson
Although critique,
means
cultivating
ingenuity
or personal
communication
are
kind
Clinical ethics approach
asking
Ijustice’
1986).
of moral dilemma regularly occurs, rather than agonising over each dilemma, it may be networks
327
l‘Ol).A\
and
b\
to
IO be able
avoiding
principle5
tar
the \ie~+
XIV
offered.
Professional conduct approach
It is, however,
based
as a decision-making This
emphasises
codes,
a knowledge
Department
regulations,
of
health
Health
authority
cies,
accountability
parts
of the law. A defensive
‘being
covered’
Of course, must but
guidelines and
procedures,
often
be included (Pyne
critical
about
This takes as its point
and regulations
contemporary
somewhere,
manner
and
and
not
of utilitarianism alliance have
been
presents would
and/or
very
Kantian
critical
have
‘reasons’
this or not doing
they such
pretend to employ as ‘utilitarianism’ ethics
model,
medical power more obvious.
in
a critique
this
model,
we must
that (Hunt
for
experts
legitimise
it
danger
accept
who for
1990). Often
metaphysical theories in a prescriptive way
is a narrowed
down
version
of
health
rooted
maintain
in the experiences
morally
system
wrongness, must
for the status
disempowerment
of’
and
amiss with
of thought then
there
of patients
expertise, and
which is the
end up providing
quo, more
OUI-
establishment.
more more
of all of us
when we become old, sick and tired. Paradoxical though it may appear, it is also important to be aware of the moral and political aims assumptions, approach to teaching everything; ideological lives.
alliance
which
of
is that if one has no sense at
care
that ethics
support
between
the
ideology
of the patterns this
and bio-ethical theory is rather Concepts such as ‘beneficence’,
which
a critique and practices,
is something
no awareness
I
1977).
Medical this
in
Elsewhere,
of departure
and nurses.
existing
standpoint rationalism
moral
which
doing
(Glover
of as
and
care systems
and
A basic assumption
technocracy.
philosophers
-
all that there
the philosophical
with medical
health
of the power
them
1992).
adopts
(doctor
with experts
Political ethics approach
Bioethics approach usually
the
poli-
clients
This
of moralit\
still places
philosopher).
this approach.
codes
of judgement
and
relevant
assumption
in the curriculum and
burden
and
hospital and
lies behind
professional
in a flexible
exclusively
of professional
on the notion process
and
methods
ethics.
it too is divided, struggle
over
Ethics
of
one’s
is not above
for it is part of the
the control
of people’s
328
NURSE EDUCATION
TODAY
This approach does not attempt to reduce moral matters to politics. Rather it is premised on an awareness that moral ends so often cannot be achieved because of political, economic and ideological obstacles (Hunt 199 1b).
References Gillon R 1986 Philosophical medical ethics. Wiley, Chichester Glover J 1977 Causing death and saving lives. Penguin, Harmondsworth Hunt G 1991a Multifaceted ethics. Nursing Standard 5 (38) : 46-47
Hunt G 1991b Nursing, patient choice and the NHS reforms. National Board for Northern Ireland, Occasional Paper No. 4, Belfast Hunt G 1992 Taking science too far. Dorset & Salisbury College, Gazette No. 2 Hunt (; 1992 Project 2000 - ethics, ambivalence & ideology. In: Slevin 0, Buckenham M, eds. Project 2000 - the teachers speak. Campion Press, Edinburgh, in press Jonsen A R, Siegler M, Winslade W J 1986 Clinical ethics. Macmillan, New York Pyne R H Professional discipline in nursing, midwifery & health visiting. 2nd ed. Blackwell. Oxford Thompson I E, Ili’elia K M, Boyd K M 1983 Nursing ethics. Churchill Livingstone, London LJKCC 1986 Project 2000: a new preparation for practice. HMSO, London.
