Laurie Gunter: Introduction
The rationale for discussing nursing ethics resides in the fact that while nurses are in situations where bioethical problems arise, they are not the predominant actors in many of these situations, yet there are ethical problems in nursing practice. There are responsibilities that have ethical and moral overtones, not only in patient care situations but in professional situations - in employment and interprofessional relationships as well as in the nurse-patient relationships. Nurses may also find themselves involved in medical research as well as in nursing research and must be prepared to consider ethical and moral issues in these particular areas. In addition, there are legal aspects of nursing that usually are not in conflict with ethical means of resolving dilemmas but must be considered.
One may raise the question of why a particular focus on nursing ethics at this particular time. In the past it was customary in nursing programs to include courses on nursing ethics and professional adjustments. These courses are not as prevalent in curriculums of today as they have been in the past. There were very strict disciplinary codes and guidelines, or codes of conduct applied to students in nursing programs then that have been dropped with a few exceptions, or possibly displaced, in today's modern curriculums.
In addition, religious training has apparently been weakened in society and with it has come much freedom of choice in terms of life styles and conduct. While this trend may be seen in a very positive light in terms of allowing for the widest possi ble choices and the greatest amount of freedom for people today, it also provides opportunities for disregard of or discarding of all, or nearly all, codes that guide behavior and relationships.
The introduction of courses in sociology and psychology have not fulfilled the need nor replaced the need for ethical guides to behaviors or for discussions where one's own ethical behaviors might be made conscious to one's self. This is not to say that people are growing up without any guides but that oftentimes what is guiding the individual is not explicit or consistent. The guides have been conveyed to the person through the acculturation processes, but in a multicultural society where people who come from a variety of different cultures or groups have to live together, it is difficult for people to know what is ethical or moral in general, particularly when the principles have not been made clear.
In this particular symposium, the focus is on some problems that may be at issue in gerontic nursing. The need for a general nursing ethics is realized and the Code for Nurses1 has been written for this purpose. In addition to this Code, there is a need to consider problems related to the various areas of specialization in nursing. This discussion is designed to meet this purpose.
A definition of ethical and the meaning of personhood and an overview of categories of ethical problems and issues will be given as a basis for the three papers that follow.
Definition of Ethical and the Meaning of Personhood
Ethics might be defined as that part of science and philosophy dealing with moral conduct, duty, and judgment - or simply standards of conduct established as a moral guide for human behavior.2 Moral behavior patterns and their systematic analysis, that is, ethics, should be a part of the character of every individual. Each one of us should follow some learned code that determines our behavior in our personal as well as professional lives.
An ethical system must have a goal in mind. It is often stated that the highest goal to be obtained by a system of ethics is that of doing the loving thing. Since the word love is ambiguous and can be used in a variety of ways it is necessary to define a certain kind of love. Thus, some have come up with the Greek term agape. Agape differs from other kinds of love in that it is more related to action than to emotion or sentiment. It basically means to act on principle out of a responsible choice that involved decision and will, as opposed to the emotions of the moment.
A system of ethics presupposes right and wrong answers to problems. It also states what is obligatory, permissible, or forbidden. One might conclude that right is the action that most elevates the personhood of self and others. Wrong is that which diminishes personhood and decreases love - the depersonalization of others is ethically wrong.
Specific Problems and Issues Involved in Gerontic Nursing
The following categories of problems and issues are presented as being of specific concern to gerontic nurses in the preservation of the human rights of the elderly:
A. Respect for human beings versus professional coercion.
B. Self-determination of clients versus paternalism in health delivery.
C. Care of the dying. . .prolongation of life versus euthanasia.
D. Rights of human subjects versus the moral justification of research.
The following problems and issues focus on the gerontic nurse as a professional:
A. Professional competence versus stagnation of knowledge, skills, and attitudes.
B. Values in the nurse-patient relationship. . .whose values should determine the care of the elderly?
Lois Heckman: Moral Choices of Professionals
I propose that a new sense of professionalism is needed within the health care professions. I believe the motivating pride in one's work and one's sense of worth and value derived from work is grounded in a sense of the right, the good, and the just that is broader than the profession itself. It is that larger "supraprofessional " meaning of care that the helping professions (which includes the nursing profession) are answerable to, and it is to this point I speak.
While some claim that the aim of professional education for each profession is to infuse in the neophyte a sense of professional identity,3 the thesis of my comments is that the aim of professional education is to infuse in the neophyte a sense of professional freedom. It is a sense of freedom that comes from within the professional and is reflected in the choices he/she makes within one-to-one interactions between caregiver and client (patient). A professional aspiring for professional freedom makes individual choices based on: "supraprofessional" moral and ethical principles, discipline of thought (scholarship), discipline of action (practitioner skills), and discipline of interaction (political astuteness). Such professional freedom permits the individual to make judgments that are independent of, can conflict with, and even refute those of his own particular professional peers.
It is accepted that the aspiring professional must learn the standards and values by which he may practice the application of his knowledge and that he learns these primarily from already accepted members of his profession. But, the professional with true professional freedom moves beyond his own socialization, beyond standards and values of his one profession, and makes decisions relative to a supraprofessional meaning of care that is a higher quality of care than is possible within one profession perspective.
Remaining both properly socialized to one profession and making departures from one's profession has moral and ethical overtones. To remain properly socialized may lead to moral and ethical blues. To engage in departures based on "supraprofessional" level of moral development and eihical principles may lead to ostracism by peers within that profession.
Observations within the real world of nursing4 tend to affirm the possibility of the relative absence of ethical principles to guide decisions in nursing practice and nursing education at all levels.
What are the universal moral principles that supersede the authority of any particular professional group? The following are three such principles:
1. Principle of beneficience - to produce good and prevent harm.
2. Principle of just distribution - fair and equitable distribution of benefits and burdens in society.
3. Principle of respect for persons - dignity and autonomy of persons promoted and protected through informed consent.
You are challenged to act on principles out of responsible choice and to do the right thing, which is to do the loving thing. The right action is that which elevates the personhood of self and others. The lesser action is that which depersonalizes the self and others.
However, as I see it, responsible choice involves more than appealing to moral principles. Responsible choice requires an adequate knowledge base, a sense of timing based on forces operating within systems, and the courage to follow one's "inner sense" into action. I would like to explore a case involving principles of beneficience, just distribution, and respect for persons, to demonstrate the complexity and the difficulty of making choices. This case is taken from autobiographical statements of outstanding contemporary nurses.
I was caring for a patient who seemed to be bleeding to death wilh liule chance of survival. The patient was 80 years old and requested that all heroic actions be discontinued, and be allowed to die. The physician refused to do this and I thought they were definitely doing the wrong; thing as the patient begged io be left alone. . .but they continued with I V's that kept infiltrating and had to be restarted, giving injections, sticking him for lab work, etc.
The first question might be, "What are the moral and eihical principles involved?" We need to consider:
1 . The principle of beneficience with two incompatible goods. It is good that quality of life be promoted by relieving unnecessary suffering and pain. It is good that physicians do all they can to preserve and restore life.
2. The principle of just distribution with two incompatible "justices." It is just distribution that society with its limited resouices allocate its resources to members who are of most benefit to society. It is just distribution that society offer limited resources to those with immediate need.
3. The principle of respect for persons with two incompatible "respects." The personhood of individuals are elevated through informed consent or when they are permitted a peaceful death. The personhood of individuals are elevated when others make sustaining decisions for those incapacitated by illness.
The case involves. a good/good, justice /justice, and respect/respect series of dilemmas. An individual is forced to choose one good against another equal good, to choose one justice against another equal justice, to choose one respect against another respect. THE PROFESSIONAL CANNOT CHOOSE BOTH AS THEY ARE INCOMPATIBLE. If professionals attempt to decide which good is more important in this case, they may end up making appeals to supraprofessional goals. With such appeals, they would probably yield to the principle of respect for persons and the patient's right to choose.*
But responsible choice involves more than appealing to moral principles. It involves an adequate knowledge base as suggested in the following questions:
1. How reliable is the prognosis?
2. Is the individual at the moment competent to make a personal decision?
3. Is the desire to discontinue treatment a settled desire rather than a spur of the moment decision?
Responsible choice also involves a sense of timing. The nurse who made the decision to withdraw from the case took the risk of looking foolish if the patient lived and being ostracized by her nursing supervisor and by the physician. But the dilemma required immediate action- either participate in the heroic actions or withdraw from the situation. The physician responded to the imperative to prolong life and the nurse to compassion for the patient and his unnecessary suffering. The nurse's withdrawal, however, did not affect what happened to the patient. Another nurse was brought in to replace her. The nurse who withdrew from the case found it necessary to consider creative ways of influencing the system in the interest of principles she upheld as most important. Her courage to follow her "inner sense" into action raised the sensitivity of her colleagues to the important issue involved.
The key to the problem of patient's rights lies in education of all professionals to move toward professional freedom, to become more aware, learn the alternatives, and evaluate personal choice. Only when given support by the professionals can the patient's right to choose become a reality. Only then can professionals claim to" be making choices as professionals that elevate their own personhood and those of their patients and clients.
Dorothy Moser: The Hospice Concept: Potential Impact in Gerontic Nursing
One concept currently being revived in health care practices (which inevitably involves aged persons and their fami lies/caregi vers) is that of the hospice. Orginally a medieval name for a Way station for pilgrims and travelers where they could be refreshed, replenished, and care for, the term hospice is now applied to an organized program of palliative and supportive care for terminally ill persons and their families. Hospice programs (which now number over 150 in varying developmental stages in the US) give rise to ethical concerns and demand the attention of individual nurses and the nursing profession.
Let me try to describe hospice care to you by sharing some of the principles that I was able to identify as I participated in a hospice program at St. Luke's Nursing Home in Sheffield, England. In identifying these principles, I will contrast them with what is the more typical picture in our western society when weenvision the care of terminally ill/dying persons;
1. There is a people focus rather than a disease focus.
2. Emphasis is on care rather than cure; this includes an intense effort to control symptoms and to relieve pain/anxiety (crucially inter-related).
3. An atmosphere of honesty and openness prevails, rather than one of deceit and avoidance.
4. The unit of care is the family, not a patient or a disease entity.
5. Goals of integration and continuity of care predominate, rather than specialization and fragmentation.
6. There is a strong sense of community, rather than isolation/alienation (not without problems for staff who dare to become involved).
7. The focus is on living, not on dying; on quality of life, not on quantity.
8. The major force is exercised through human caring* rather than high technology.
9. The total approach is a loving/caring one with potential for growth extended to all, rather than an impersonal, destructive attitude associated with feelings of defeat/decline.
Now, allow me to share some observations from the hospice experience that reflect its philosophy of care:
1. Very little evidence of technology- no oxygen, no nasogastric tubes, no IV's, no suctioning apparatus, no bedside rails or restraints, no cardiac monitoring devices (the matron boasted that the two most important machines there were the ice-maker and the hairdryer).
2. Dying people who looked comfortable, not in pain, alert, out of bed, looking forward to meals and enjoying their visitors and contacts with staff.
3. Staff and volunteers who truly functioned as if no hierarchy existed - more as concerned family members than professional caregivers (exemplified in the shift reports that were beautiful exchanges about the whole St. Luke's family and were just as apt to focus on the dying person as on a grieving family member or a distraught staff member).
4. No large nurse's station, but merely a small counter and record storage area, where it was rare to find more than one person and from which the entrance to all patient rooms was visible.
5. Call lights outside every room- rarely lit - because the staffing pattern of 1:1 made it unusual for a patient not to have someone within sight to meet an immediate need (what was lacking in technology/equipment was more than compensated for by people power - the number of volunteers was phenomenal and there was a long waiting list for employment).
Dr. Gunter suggested, in the introduction, some specific problems and issues of concern to gerontic nurses. I would like to suggest how the hospice concept relates to each of these concerns. First, nurses are concerned about respect for human beings versus professional coercion. Nurses and other health professionals tend to reflect the same attitudes as are prevalent in society at large. They are, thus, contributors to what seems to be a coercive force aimed at denying old age, equating old age with death, viewing of old age as a decline/fail ure/noncontributing phase, and sanctioning the removal of persons from the mainstream of society (hence, the statistics that about 85% of persons in the US die in institutions, only about 15% at home - figures that are reversed in Britain). The hospice movement focuses on care in the home, control of symptoms to foster meaningful relationships, and a family approach that holds potential for changing attitudes of future generations towards death, dying, and old age. The association of a hospice program with either a nursing home or an acute hospital could have a significant effect on the attitudes of persons in those institutions.
A second concern of gerontic nurses is the preservation of self-determination of clients versus paternalism in health delivery. The hospice concept at least offers another alternative for care in terminal illness. One need not remain in the cure-oriented system, submitting to painful and dignity-denying interventions if one prefers not to. When our present system says "there is nothing more we can do," the hospice offers many caring interventions in a milieu of patient/family autonomy. In that milieu, nurses also have increased opportunities to function autonomously as professionals.
A third concern of gerontic nurses is related to the dying process itself. Many questions arise even when one is dying a "normal death" after 80 or more years of productive living. Should life be prolonged as long as man has the means and technology to do so? Should death be hastened by some form of passive or active euthanasia? Some critics of the hospice movement view it as a form of passive euthanasia and even express fears about this being a prelude to genecide. Yet the hospice concept focuses on living, not on dying; on preservation of quality of life. I must comment that I never heard a patient in the hospice program request release from life or plea to be allowed to die (in sharp contrast to frequent comments 1 have heard from patients in our nursing homes to "let me die" or "why doesn't the lord take me?" - I'm sure you've heard these remarks). Some would even say that the hospice may serve to lengthen life because the program reduces anxiety/stress on the body.
Finally, Gunter also suggests that gerontic nurses are concerned about the rights of human subjects versus the moral justification of research. The dying experience in an acute hospital is influenced by such things as the need to try new treatments or surgery, the need for residents to learn, and the pressure for autopsy permission. Hospice care, on the other hand, is not concerned with applying new procedures or other curative techniques that raise ethical questions. Because the family is the unit of care, proxy consent is not a problem; hospice staff know family members and their attitudes as well as they know the dying person's. Informed consent just is not a problem in an environment of openness and honesty. Recall that the aim of hospice is to keep the dying person at home. Many of the ethical dilemmas related to research and treatment that arise in acute care settings simply are nonexistent in the home.
Gunter also referred to two issues that pertain to nurses as professionals. The first issue has to do with professional competence versus stagnation of knowledge, skills, and attitudes. I agree that it is deplorable that nurses, as the largest group of health providers, have such a small voice when it comes to decisionmaking on health matters (whether at the clinical practice level or at the public policy level). It is imperative that nurses, via basic educational or continuing education programs, be knowledgeable about options open to the consumer, contribute to the decisions about the kind of services that will be available, develop collaborative skills in order to foster implementation of care programs, exert collective action through their professional organization, and be informed and influence health-related legislative efforts. I believe that nursing is ethically obligated to pursue new knowledge and to evaluate new options for care.
A second issue that pertains to nurses as professionals is related to the values in the nurse-patient relationship. Whose values should determine health care? Nurses need to consider value orientations of clients when planning and giving nursing care. Do nurses really know their own values related to matters of aging nd death, let alone appreciate the diverse value orientations of their clients? Nursing of the aged and/or dying offers a unique opportunity for values clarification for the nurse as well as the privilege of helping clients clarify values. The hospice program can foster autonomous action by both nurse and patient/family, based on their respective value orientations. Nursing education programs need to provide curricular experiences related to moral growth and development; the use of hospice programs as student placements might facilitate such learning. Clients in a hospice program are viewed in a much more personal way and have more autonomy than in traditional acute care settings where depersonalization is rampant and where decisions are frequently made without their input.
In conclusion, we may consider the following questions. Is the hospice movement a morally right one? Should such an option be available to terminally ill persons in the US? Should nurses, collectively, support hospice care? Can individual nurses feel ethically comfortable as participants in hospiceoriented practice? The knowledge explosion, scientific advances, burgeoning technology, social/political forces - all have brought us to this time of ethical crisis. Can we avoid confrontation? Could we, as individuals, as a profession, as a society, reach new heights of human achievement as a restili of risking the discomfort possibly encountered? Hospice is, indeed, a concept with an exiciting challenge!
Marie Fasano: Issues Faced by Older Families
As a nursing consultant to skilled nursing facilities, I often talk with residents or families when the director of nursing feels there is further intervention needed. A very worried relative came to talk with me, "My father came to the nursing home yesterday. The doctor said he couldn't take care of himself any more. He still has his house. He wants to go home. I can't afford to have a fulltime person there taking care of him. How can I sell his house and get rid of everything? He's had it for 40 years. What should I do?"
A school administrator calls me and says, "Marie, this older couple who are friends of mine is in trouble. Stan called and said 'Margaret is failing. She doesn't remember what she's doing and she's very unsteady on her feet. The other day she burned herself on the stove.' He broke down and cried saying, 'I'm going to have to put her in a home. What else can I do?' Marie, can you talk to him?"
Another call from a nurse who works with the elderly. "I have a friend who lives with her mother. They are good friends of mine and I am worried about her mother. She goes to the doctor but he doesn't seem to be helping her. I think she's taking too many different pills. What can I do to help?"
These are examples of issues that face older families every day. Decisions are made, but often without necessary information and more importantly, without a support system of people who can work with the family through the problem-solving process. Nurses, more than other groups, often come in contact with older familes during these crisis times when placement decisions are to be made. We can be very instrumental in assisting families with problem-solving and decisionmaking. We can do this by first being aware of the resources in the community. It is very important to have a contact person in all the key agencies in your community. Second, the nurse needs to be a skilled interviewer and listener. This is a person who will work with the older family in assisting them to identify the salient issues with which they are confronted. Third, as a gerontic nurse she will be knowledgeable about the usual changes with age and the diseases that may cause a disruption in that process. Finally, the atmosphere in which this takes place must be a supportive one.
I am currently in the process of developing a community plan to assist older families in this decision-making process. The community plan has four components:
1. Monthly Sunday afternoon meetings held in a place accessible to older persons. The title is "Living in the Later Years." The meetiiigs will be free, informal, with a chosen topic each month by a chosen speaker.
2. Ongoing weekly group sessions held by myself and a social worker to discuss the current crisis situations the family is encountering and provide needed information for them to make a decision.
3. Weekly group therapy sessions made available to these families to work through continued relationship difficulties.
4. Individual sessions for the older family members during the day and evening whenever the need arises.
This is the plan, then, to meet one need that is not currently met in the community. Older families will get needed information. They will have knowledgeable, supportive persons assisting them with the decisionmaking process at a time of crisis in their lives. Ongoing counseling will be available for families to assist them during this transition period. In this way we are filling a gap in community services for older families.
Laurie Gunter: Closing Remarks
At least two main principles have been demonstrated in providing care to the aged in this symposium.
1. Respect for the personhood of others. Fletcher states, "The patient is not a problem; he is a person with a problem."5 A person or personhood has been defined as having that quality of life that possesses the ability for free and responsible behavior. When patients are manipulated as things, their personhood is rejected. Each elderly person has the right to be related to as a person and not as a problem or disease that needs treating for its own sake.
2. Concept of the whole person. Like everyone else, the elderly have physical, emotional, intellectual, and spiritual elements of their being. The ethical gerontic nurse ministers to all of these aspects of the whole person.
While putting the responsibility and decisionmaking on the patient to strive in improving his own health and well-being, the nurse is to provide guidance, skill, pleasant setting, information, encouragement, and a sense of value in living fully to the extent possible.
Use of these principles will serve to guide the provision of quality care for the elderly.
- 1. American Nurses' Association: Pet speri i ves On the Ckxie for Nurses. Kansas City, Missouri, American Nurses' Association, 1978. p 60.
- 2. Hitchcock BE: A personal code of ethics. Nursing Homes 17:1819. August 1968.
- 3. Anderson GL: Professional education: Present status anil continuing problems, in Henry NB (ed): Education for the Professions: The Sixty-first Yearbook of the National Society for the Study of Education, pi 2. Chicago, Hildmanu Printing Company, 1915, pp 579-590.
- 4. Heckman LH: The professional development of nurses, a humanistic perspective. A thesis. The Pennsylvania State University. March 1977.
- 5. Fletcher J: Morals and Medicine. Boston. Beacon Press, 1951. p 37.