Ethics for Nursing and Healthcare Practice

Kath M Melia

• Publisher: SAGE Publications Ltd
• Year: 2013
• ISBN:
  9781446292686
• Edition: 1
• Topic: Medicina
• Subtopic: Enfermería

Everyday clinical practice is steeped in ethical considerations, but discussion of ethics is often removed from these real-life situations. Kath M Melia?s new book works in the gap between theory and practice. The chapters tackle the main theories which form the discussion on ethics, and include practical case examples, which bring these theories into the clinical context. These classic and everyday cases challenge the reader to critically reflect on his/her own experiences and outlook.

The social, legal and professional regulation context is brought into the discussion throughout, to equip students with the knowledge that they need to make clinical decisions.

Topics covered include:

- Beauchamp and Childress? four principles of bioethics

- Rights

- Personal and individual conscience

- Moral philosophy

- The virtues/virtue ethics of the practitioner.

This book will be essential reading for pre-registration nursing students taking modules in ethics and law. It will also be a valuable text for postgraduates and qualified nurses, and students of health who need to gain an appreciation of ethics.

1 Introduction

Life is short, and Art long; the crisis fleeting, experience perilous, and decision difficult.

Hippocrates, 5th Century BC

Practical questions such as Should this patient continue to be fed artificially? are rarely simply technical matters. They carry concerns of fairness, rights, compromised freedom and justice. We often speak of the moral dimension of practice but it is perhaps more accurate to regard moral matters as being so bound up with the technical and social aspects of caring that to separate them out as a discrete item for discussion is not easy and possibly not helpful. The work of nurses and other health care professionals entails human contact. Decisions about care are matters of judgement; these are clinical judgements which, of course, also involve the patient. There will also be circumstances where this is not possible and the patient's relatives1 and/or legal representative can be involved. Nursing practice does not occur in a moral vacuum; the organisation of health care means that nurses work with other professionals making up the multidisciplinary team. The wider social context within which the decisions are made also has its influence on practice. Given all of this, we need to be clear about what ethics is and why we should be concerned with it in nursing practice.

1 Throughout the book I use ‘relatives’ to refer to family and friends representing the patient's interests. I do so on the grounds that friends are related by friendship, whereas family need not imply friend.

Ethics, or moral philosophy, is the branch of philosophy that is concerned with the study of morals and the nature of morality. It is of practical value to clinicians in health care as it provides the language and concepts with which to argue for and justify a particular decision or action. In other words, it allows us to judge our own moral convictions and values against wider, socially accepted principles and rules for behaviour. Morality has to do with a sense of right and wrong. But where does this come from? Can it be taught?

This book concerns the moral dimension of nursing and health care practice. It is in no way a rule book, or even guide as to how to avoid ethical traps. Health care is a complex matter and nursing plays a central part in its practice. Situations arise in daily nursing practice which involve a decision to be made that is both a clinical and moral decision. In this book we take a down-to-earth, case-based approach to ethics. Essentially ethics is about the reasoning behind the decisions we take, and it forces us to think about what is the right thing to do in life. In the case of nursing practice, ethics is about how to decide how to act as a nurse.

In a society that has advanced to the point that a complex division of labour exists, health care is a professionalised activity and those being cared for will be, by and large, unknown to those doing the caring. Put simply, we have two sets of strangers, patients and professionals, who have to relate to each other in order to produce a working partnership, however transient. This is not, of course, to say that relationships do not develop; long-standing professional–patient relationships exist in all areas of practice. However, the point stands because even strong patient–professional relationships had to start somewhere. Nursing practice involves patient and professional coming together and arriving at a position where communication and care are brought about in a relationship which should be based on trust.

This book is an introduction to ethics for nursing and health care practice and stresses the importance of the social context in which this takes place. The idea is to introduce the moral philosophical language in which practical clinical issues2 are discussed. The relationship between ethics and the law is a theme that runs through the book and so provides a basis for a good understanding of ethics and law as they relate to nursing practice. Ethical decisions are arrived at in practice in a social and legal context. Sociology is drawn upon where it can help to explain the social and organisational context of practice. Whilst this is an introductory text to ethics for practice, the aim is to discuss some of the complexities of ethical debate. The book starts from scratch, assuming no prior knowledge of ethics or law; however, the discussions can lead to a sophisticated level of debate, but a debate which remains firmly rooted in practice.

2 ‘Issue’ in this text carries the long-standing meaning and does not equate to ‘problem’. Issue, meaning a topic for discussion, is a more neutral term used to describe matters worthy of discussion which may or may not be problematic. In many places I have used ‘concerns’ or ‘matters’ instead of ‘issues’ to avoid confusion for those who do equate ‘issue’ with ‘problem’.

Ethics Morals and Practical Reasoning

Nursing practice is a complex business and it is expected, indeed assumed, that nurses will behave in an ethically acceptable way. In this book we explore exactly what this entails and through the discussion of cases we enter the world of the moral philosopher, and in so doing see what light moral philosophy can shed on the moral dimension of nursing. This book is not a comprehensive account of ethics for nursing practice, rather it seeks to convey the central principles and their relationship to ethical debates in such a way as to nudge readers towards an examination of their own clinical experience and focus on the ethical aspects of practice.

Whilst ethics and morals have to do with right and wrong, they are not about dictating what we should and should not do. The distinction between morals and ethics is worth spending a little time on, although the terms are often used interchangeably. ‘Morals’ refers to the values and associated rules and practices by which people live, whereas ‘ethics’ is that branch of philosophy called moral philosophy, which is concerned with the study of morality.

Some writers prefer not to draw the distinction, pointing out that both words – ethics and morality – have their roots in words meaning ‘customs’ and as such are not really different, despite the distinction. ‘Ethics’ derives from the Greek ethikos which gives us the word ‘ethos’. ‘Morals’ derives from the Latin moralis, meaning mores. Both words mean customs and ways of life followed and passed down through generations (Singer, 1994: 5). Singer also notes that ethics is a more neutral term and the word morality can convey a particularly religious resonance.

Within the health care literature I find that both ethics and morals are used interchangeably whilst at times the distinction is recognised, and so in this book I do not adopt a rigid approach to their use. Ethics is essentially about the study of morals and is generally about right and wrong. The terms ethics and morals whilst distinct can be used interchangeably without much harm coming to the discipline of moral philosophy. Nor, indeed, will any harm come to the study of ethics for nursing practice if we slip between the terms morals (the values and mores of behaviour) and ethics (moral philosophy, concerned with the study of morals).

The business of ethics is to examine the justifications offered for the various moral stances that people take on questions where there are various opinions and where decisions have to be made. In the face of an ethical dilemma where, by definition, it is not clear which action is the best option to take, moral philosophy offers the language and concepts with which to debate the matter. It also allows us to draw on a wider range of principles and theoretical positions which have stood the test of time and public debate. For example, the idea of respecting individual's rights to be treated in ways which are deemed to be acceptable and fair forms the basis of many discussions of resources. The use of resources can give rise to everyday questions which might appear to be trivial matters, such as making the best use of the available staff time on a shift in order to achieve the best outcomes for the patients on that unit.

A busy morning on a ward which has been the main admission ward overnight. There is a shortage of linen. There are not enough sheets to enable as many to be changed as would be desirable. The nurses on duty, having established that there will be no more sheets delivered to the ward until the afternoon, have to do the best they can. The practical solution is to change those that cannot be left, and catch up later in the day with the rest when new stocks arrive.

There are organisational and maybe even financial considerations here. How should nurses react to this compromise of optimum patient care? In a busy ward the answer may be to make do and move on. But what if this is a common occurrence? If nurses always manage to cope, the situation may go unchanged, like the sheets! Is there an obligation to speak out in an attempt to make things better? And what if managing, quietly getting on with it, extends to other areas of care? Where should nurses hold, or even draw the line and speak out?

This question, which set out as a matter of what to do when there is a shortage of bed linen, has moral aspects to it. Moral choices, albeit small ones, are made in deciding who gets a clean sheet, and by default who does not. The right to a clean sheet is not an absolute one; our rights are often set against those of others – if one person's need is satisfied in a rationing situation, another person's is not. The greater need that one person has of the clean sheet does not alter the fact that the person with less need did not get a clean sheet. This not very dramatic example of moral choice is just one of many similar choices made by nurses in relation to the daily care of patients.

Ethical Debate

It is worth rehearsing the reasons why ethical debate is important; one of the main ones is that when vulnerable people are being cared for by strangers, there has to be an atmosphere of trust. We create this by developing a context for a professional–patient relationship. In order to achieve this we need some ground rules, and some of these rules are the concern of ethics. Ethical analysis and debate provide a way of examining and discussing the rights and wrongs of behaviour in health care. What is in the patient's best interests? How should we be caring for this patient? Is this a reasonable way to run a ward? How should we respond to aggressive behaviour in patients and their relatives? These are all questions for moral philosophy. We need a common language and a way of debating the rights and wrongs of how to go about nursing and health care, especially when things are not straightforward. We find this language in moral philosophy.

One of the interesting aspects of ethical debate is that there are no rights and wrongs about it. Leaving aside views that might be regarded as being beyond anyone's pale, ethical debate takes on board all moral arguments that are reasoned attempts at making a genuine effort to decide on the right action to take when faced with a difficult situation.

Philosophy is very much concerned with what is the right thing to do, how people justify their positions when making moral decisions. Moral decisions are very much like clinical decisions, they have practical connections and consequences and a social context. Ethics is a very practical business: decisions in health care have legal, moral, clinical, economic and psychosocial aspects.

In the midst of everyday practice there is rarely time to step back and ask are we doing the right thing, what should we do? In this day of protocols, evidence-based practice, audit trails and the rest, there is not a moral procedure book to consult. Yes, there are codes of conduct, ethical discussions, but in day-to-day practice there comes a point where practitioners working together with patients have to arrive at a decision; this is very much the social production of action. In other words, it is a practical matter, it is practical reasoning. Ethical debate gives an opportunity to explore moral issues using the language and concepts of moral philosophy. This means that we cannot take our usual ideas and stands on particular issues for granted, and this includes our prejudices. We do not tend to regard our own views and opinions on social matters as prejudices, they are just what we think. They may be strong enough convictions to make us disapprove of others who do not happen to share our opinion. When someone expresses what in our view is an unacceptable opinion during a general conversation, it can be difficult, especially if their assumption is that it is a shared view, and an unproblematic one at that. These views may be racist or sexist or offensive in some other way. These situations make two things clear: first, what we might assume to be a reasonable and common-sense view to hold is not necessarily a universal understanding; and second, it is not always easy to register our objection because it takes us out of the normal expectations and conventions of conversation in social life. Clearly there has to be a good deal of common understandings and beliefs if society is to function, and later in the book we return to this idea in a discussion of societal norms and expectations and the law.

My general point at this juncture is that we cannot always assume that others will automatically share the views that we, as individuals, hold about right and wrong. This is especially important for a professional group such as nursing where there is a need for shared values in the profession. There also has to be a means of engaging with a wide variety of patients who have other views and values.

In everyday life we do not normally try to investigate the justifications for the values that we hold. Moral philosophy at its simplest gives us a means by which to do this. As we have said, ethics is a deeply practical business; without real life practical examples to relate to, ethical debate is somewhat sterile. The discussions in this book are centred around a few classic and some hypothetical cases which give rise to ethical and sometimes legal and ethical debate. The clinical context can be supplied by the reader. The main aim of the book ...