Ethical Dilemmas and Nursing Practice (Book Reviews)

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  • HIS book is primarily a collection of essays that reflect the T authors views on a variety of bio-ethical issues and the impact these issues may/do have on nursing practice. The authors goal is to assist nurses to become more aware of

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  • ethical dilemmas in health science and in nursing practice. (p. viii) There is little doubt that this goal will be achieved and no doubt that serious discussions and controversy will be pro- voked among nurses, philosophers, and other interested readers.

    The first three chapters of the book are devoted to an ex- ploration of the meaning of health care ethics, professional ethics, ethics as a discipline, and to a historical/sociological exposition of ethics in the nursing context. The explanations of the various ethical theories, however, are far too brief, do little justice to the various philosophers cited, and are often unnecessarily confusing. The authors define health care ethics as normative ethics specific to the health sciences in that it raises questions as to what is right or what ought to be done in a health science situation that calls for a moral decision (p. 4), yet limit its function ( 1) to sensitize and raise the con- sciousness of health professionals . , . concerning ethical issues found in health care settings and policies and (2) to structure the issues so that ethically relevant threads of a complex situation can be drawn out. (p. 5 )

    The definition suggests that norms, rules, or guides for conduct (presumably meaningful ones) can be derived from the application of certain principles to specific situations. The designation of the function, however, limits this emerging discipline to a phenomenological or purely descriptive role. Perhaps what the authors wanted to say was that ethics as a discipline (applied to the health sciences or elsewhere) can help us in making moral decisions by teaching us what to consider and how to consider it.

    The single most controversial section in this book has to do with its arbitrary dismissal of the concept of natural human

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  • rights. In only seven sentences the authors dispose of universal and inherent human rights and appear to espouse the notion that rights are derived from the state and ordered by law. (p. 46) As the authors evidently refer to the United Nations Declaration on Human Rights (based as it is on a concept of universal and inherent human rights), one is led to wonder if they realize what this position entails. For example, later in the same section, the authors state that another aspect of the confusion is that one can justifiably claim to possess a right even though that claim is currently unprotected by law or social custom. (p. 47) What must be realized is that if the state is the source as well as the protector of all rights, no justifiable claim can be made for any so-called right not already recognized by law. The state may also legitimately modify or remove rights as it sees fit or necessary and the citizenry has no moral right to resist or object.

    The critical distinction that must be made is the distinction between having a right and being able to exercise that right. Clearly it would be difficult, if not impossible, to exercise a right that is not protected by law. Just as clearly, a justifiable claim conveys the notion that one already has the right and is petitioning (or demanding) to have it recognized by law. There are, of course, such things as purely legal rights, but the con- cept of natural human rights places these particular entities philosophically prior to law.

    Although some modern philosophers do hold the view that all rights derive from the state and are ordered by law, by no means is this universally true as the authors seem to imply in their general statement that this is the modern world view (of rights). (p. 46) To cite just one easily understood and

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  • rather broadly accepted alternative view, the foundation of any democratic system is based on the idea that the govern- ment derives its authority from the consent of the governed. The person is the repository of rights and the state derives its authority to rule from the collective consent of the people. In this view, a government is legitimate only in so far as it protects the rights of individuals and arbitrates conflict-of- rights situations.

    If, however, the state is the source of all rights, the in- dividual has no legitimate recourse. Thus, although the authors deplore the excesses of the Nazi human experimentations and extol the Nuremburg Code in their section on informed consent (p. 69), they fail to recognize that ( 1) what the Nazi physi- cians did was completely legal in Germany (and therefore in this view, just, good and proper); and (2) the Nuremburg Code was based on a concept of universally applicable natural human rights. If one holds the view that the state is the source (not merely the protector) of all rights, then the Crimes Against Humanity condemned at Nuremburg simply did not exist and, in fact, the legitimacy of the Court of Nuremburg can be fundamentally questioned.

    Chapters five through ten, which deal with specific ethical issues such as, abortion, behavior control, death and dying, reflect a confusion about concepts of human and legal rights. Many times the authors seem to be basing their reflections on a concept of rights as universally applicable and inherent. At other times, all rights seem to be reduced to legal entities. These essays would have been far better developed, coherent, and concise if the authors had laid a consistent foundation for a theory of rights upon which to base their reflections. They do,

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  • however, point out that nurses are involved in such issues and do have ethical responsibilities.

    The final chapter is devoted to selected examples (case studies) of ethical dilemmas nurses face in their practice. Al- though the case studies themselves are interesting, many are not unique to or even modified by nursing. Further, the reader may be justifiably confused by the questions the authors derive from these case studies for discussion. They often seem to have no direct (or even indirect) connection with the cases and often serve to confuse issues or extend issues so broadly as to make rational reflection on the case at hand impossible. This, of course, further clouds and confuses the decision-making process. Again, to cite but one example, the authors suggest that an appropriate question deriving from an abortion case study (in which an 18-year-old girl did not want an abortion, even though not married and carrying a potentially damaged fetus) is whether the nurse should use coercion to force an abortion. (p. 209) This question implies that a nurse (or any- one) in a counseling situation, has the authority to use coercion in some circumstances - a highly questionable assumption!

    Perhaps most perplexing of all to this reviewer is what is not contained in this book. Why did the authors omit an in-depth discussion of the nurse-patient relationship? Threads of the authors views can be found in various places throughout the book, but no clear foundation is presented. Although the authors bring up the subject of nurses rights (specifically autonomy), they do not lay a philosophical foundation for such a claim nor do they attempt to justify the claim. It would seem to me that these two issues are central to any discussion of ethics and ethical dilemmas in nursing. The right and duty

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  • of the nurse to act in the patients behalf is directly derived from the nurse-patient relationship, and any system of ethics pre- supposes an agent (in this case the nurse) who is free to act.

    The reader may also justifiably wonder why the entire section on informed consent is devoted to human experimentation when nurses daily confront consent problems in their ordinary practice. Certainly the problem of informed consent is not limited to research and is commonly found throughout the health care endeavor.

    Perhaps this book should be viewed as a first attempt to come to grips with the ethical practice of nursing in todays world - the first, it is hoped, of a growing body of literature on this subject. For this reason alone, its importance should not be underestimated.

    LEAH L. CURTIN, R.N., M.S., M . A . Director, National Center for Nursing Ethics Cincinnati, Ohio

    THE DAVIS and Aroskar volume is a welcome text at a time of great ethical uncertainty in the health care system. The two authors, fresh from a year of post-doctoral study under the aegis of Kennedy Fellowships, have produced a book that is worth reading as a stimulus to ethic21 thought. The need for books about ethics that are more than social etiquette has not been met for a long time.

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  • The authors bravely take on topics of highly emotional con- tent in which there is a great deal of ambiguity as to appro- priate ethical behavior. The rights of patients in the health care system, informed consent, abortion, death and dying, behavior control, mental retardation, and public policy and health care delivery systems are major areas addressed in the book.

    Of the various theme chapters, the authors best state their case in the chapter on behavior control. This may stand out because there are so many publicly and professionally ignored ethical issues in the management of persons with emotional instability.

    The book, however, has weaknesses as well as strengths. The authors, for example, do not state to what level of preparation for nursing practice their book is oriented. It does not seem possible that nurses from two-and-three-year programs that do not have strong strands of humanities can search through the content with the understanding of university graduates. To cope reliably with some of the conceptual levels of abstrac- tion and ethical issues discussed in the text a student would require all the learning inherent in graduate education.

    Although one might conclude that the authors take the normative position from which they analyze ethical behavior and position, this is not stated clearly. Normative or applied ethics, they state, attempts to justify one form of behavior over another, to determine the right-making characteristics of action for purposes of carrying out duties and obligations. The nurse, often in a situation vis ii vis a patient, group, or com- munity that requires the identification of alternative courses of action, must make a choice as to what he or she will do when there is a conflict of rights and obligations between patients,

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  • families, other health workers and the community. The authors point out in an insightful way that the reflective think- ing required to accomplish this end is analogous to the methods of thinking in science, and that reflective and scientific think- ing are not mutually exclusive. This is a highly interesting observation, but it raises the question as to how many nurses are trained in the method of thinking used in the scientific endeavor. When this question is answered, one must conclude that a very large percentage of the nurses giving direct care to patients do not have this skill. What to do then becomes the question that is not answered in this book.

    In their chapter on Professional Ethics and Institutional Constraints on Nursing Practice, the authors retreat to the easy position of placing most of the blame on the position of women and, hence, nurses in our society. As a basic premise, this is open to challenge. The authors appear to ignore all other structural dimensions, which is hardly a defensible position for scholars to take. For example, they do not comment on team nursing, a device invented by nurses as a preferred way of giving care. When one examines team nursing, it is shown as a perfect means of avoiding accountability. Masses of nurses give care to crowds of patients in a functional way that aborts the ethical process. If nurses are not in a primary accountable pattern with clients or patients, they need not deal consistently and rigorously with ethical concerns. Outcomes for patients are dubious. If nurses wished to be more accountable and ethical, they would abandon team nursing overnight. This is not a state of affairs forced on them by physicians/men. It should be noted that the men in nursing act similar to the women in the profession on all structural variables, so it is a professional

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  • nurse characteristic rather than a male or female behavior. The same analogous comment can be made about the much

    asserted concepts of technical and professional nursing. All nurses need cognitive and psychomotor skills; it is highly questionable as to their reality in the empirical world of patient care. If these concepts are carried out in practice as if they were valid, then the non-thinking technical nurses would be doing the bulk of the direct care and not be plagued by ethical considerations. They would merely carry on by routines, pro- cedures, policies, and rules. Certainly this automatic behavior type of care does not delve deeply into ethical considerations. Professional nurses, apparently once removed from direct care, may fret about ethical dilemmas but by not being directly in- volved with patients may not have all the impact of the subtleties of ethical issues confronting them. This retreat from reality is not forced upon nurses by any other group. It is another example of a smoke screen to avoid responsibility.

    Nurse educators, for the most part, demonstrate an un- willingness to become involved with patients - and, thus, the ethical issues - except through such safe, distant, and aloof means as through the practice of students. If nurse edu- cators are the best prepared nurses in the country, then it be- comes apparent that by deliberate design and willful intent they are withholding their services from patients. Most of them are not giving service in an accountable fashion so as to serve as behavior models to their students. It is safer to retreat behind the rhetoric of the classroom than to be exposed on the firing line the way the educators of other clinical professions are while providing behavior models for students. No one is forcing this non-accountable model on nurse educators. It is one of

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  • free choice. The great reluctance of nurses to adopt a generic model of

    education that would provide for induction into the thinking demanded by the rigors of science is another area that shows the reluctance of nurses to become accountable. As a com- panion observation, the avoidance of graduate study demon- strates a certain anti-intellectual bias. The authors themselves state that ethical thinking is a highly intellectual enterprise. No outside group is forcing nurses not to be interested in progres- sive career development by using the same model of graduate study that all other disciplines and professions employ. This is a decision made freely by nurses.

    It becomes apparent on examining only a few structural issues within the profession that the dearth of insight into ethical action is a product of nursing education and nursing practice and not primarily a weakness forced upon nurses by others. The rate of progress toward achieving a better base for ethical practice lies within the profession itself. One cannot effectively become a patient advocate in a system of education and practice that is not articulated, holistic, and accountable.

    Despite the reservations noted above, this book is worth reading and reflecting upon its content. Let us hope it will open up ethical areas to further exploration, further literature, and as a result, better service to patients.

    LUTHER CHRISTMAN, R.N., PH.D. Professor of Nursing and Dean College of Nursing Rush University Chicago, Illinois

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