Ethical dilemmas in nursing - Journal of Medical Ethics

1 Journalofmedicalethics,1986,12,123-126,1 35 EthicaldilemmasinnursingJeniferWilson-Ba rnettKingsCollege,LondonAuthor' ,inter-projessionalcommunicationsarefreq uentlyinadequate, ' , ,thespiritofservitudeandobediencequestio nedbyNightingale(1),butperpetuatedbymany nursessince, (2).Increasinglynowhowever,nursesarereal isingtheirtherapeuticpotential, ,especiallywhentheyhavegoodreasonstodisa greeandarefacedwithtreatmentconsequences continuallyduringtheirdailywork(3).Ethic alissuesinnursingmustthereforebeviewedwi thinacontextofanemergingprofessionalcons cience,withinamulti-disciplinaryteaminwh ichnurseshavegenerallyheldasomewhatsubor dinaterole,andinasituationwheretheyhavem ostcontact(orcouldhave) ;nurses;paternalism; , , ,requireassistancetomanagedailylivingact ivitiesandtheirproblemsarepractical,econ omicandsocial(4).

2 , ,ontheotherhand,areattemptingtocareforpe oplebyunderstandingtheirpersonalstrength s,motivationsandothersupportiveresources (5). (6).Thisneedstime,patience,knowledge, 'welfare, ,butitshouldalsoinvolveassessingandrepor tingpatients' , on April 9, 2022 by guest. Protected Med Ethics : first published as on 1 September 1986. Downloaded from 124 JeniferWilson-BarnettLoweredstatus,inade quatepreparationand(largely) ,othersmorerecentlytrained,areeagertocon tributemoreoftheirintellectual,rational, , , (7).However,anxietyreductionisalsoavital partofthisprocess,andansweringallthepati ent' ,butthevexedquestionsonalternativeformso ftreatmentorratesofrisk, 'strustinhisdoctorisessentialandusuallyn otdifficult, , , ;forinstanceCulverandGertgivemanyreasons whynursescanprovideinformationanddiscuss treatmentplansmoreeffectivelythanothers, andinconclusionsay:'.

3 Makingnursesinin-patientsettingsresponsi blefordeterminingthatthepatienthasadequa teinformationforgivingvalidconsentwouldh elptoinstitutionalisethenurse'sroleaspat ientadvocate,andthusmakeitthenurse'sprof essionaldutytoprotectthepatientfrommakin gdecisionsbaseduponinadequateinformation '(8).Thisassertionrestsonfaiththatnurses haveadequateknowledge, , ' (7).Thisaspectofthenurse'sroleshouldbepr omotedforthepatients'benefit,yetitisperh apsprofessionalrespectbetweendoctorsandn urseswhichmustgrow,inordertopermitfrankd iscussionsandquestionswheneitherdisagree withtheirtreatmentplans,orwhenthenursefe elssheshouldrelaythepatient' 'decisionsrelatestothepaststructureofmed icineandnursing, ,inmedicineandinnursinghaverequiredclear linesofauthority, , 'theservice'. (orlackofit)werejustifiedinthepastthroug habeliefinbenignpaternalism:doctorsknewm oreaboutmedicinethanothers, ' (9) 'slibertyofactionjustifiedbyreasonsrefer ringexclusivelytothewelfare,good,happine ss,needs,interestsorvaluesofthepersonbei ngcoerced.

4 'Actingforsomeone'sbenefit,notnecessaril yagainstbutwithouthisorherconsentseemsto happenagreatdealinhealthcare, (ormaternalism)isverycommon,particularly withelderlypeoplewhoaretooweakorconfused torefuseallthewashingandexercisetheyaref orcedtoreceive(10).However,therecentchan gesinnursingphilosophywhichemphasiseshar edgoalsandmaximalpatientparticipationatt empttocombatthis(11).Medicalpracticeisal sorecognisingthebenefitsofnegotiationand collaborationtocopyright. on April 9, 2022 by guest. Protected Med Ethics : first published as on 1 September 1986. Downloaded from Ethicaldilemmasinnursing125encourage'com pliance'(12).IndeedWeiss'smodificationor modernisationofthemeaningofmedicalpatern alismincludesanaccurateappraisalbythedoc torofthepatient'svalues,priortodecision- making(13).Medicalpaternalismwithrespect tonurses,however, , 'paternalismisinterferencewithaperson'sf reedomofactionorfreedomofinformation'.

5 (14) (15), , , ' 'scare:notonlythepatientandhisorherrelat ivesbutseveralnurses,physiotherapists, , , ' , ) 'nothingtolivefor', ,andsemi-conscious, , , )Afifty-year-oldladyhadbeenadmittedforin vestigationofindigestion, 'verynervous' on April 9, 2022 by guest. Protected Med Ethics : first published as on 1 September 1986. Downloaded from 'sfearsofcancerpreviously,thenurserealis edthatshemightinduceseveredistressifshem entionedthisalthoughthepatienthadconfide dthatshewouldnotbeafraidofdying'aslongas itwasn'tcancer'.Despitefeelingthatshewas beingaskedtodisclosethelimitedprognosisa t thistimeandknowingthatshewouldbeavailabl etosupportthepatientfortherestoftheday, , anissueattimes,butasBrewin(16)hassaiditi smoreoftenacaseofprovidingskilled,open, ) 'clockthateveningandhewasrathershockedby thepatient' , , 'sirritationandhethencomplainedaboutthen ursetothewardsister, , ,itcanalsoreducethequalityofcareintended (asillustratedinthevignettesabove).

6 ,King'sCollege, (1) :DoverPublications,1969:130-133.(2) :DavisC, :CroomHelm,1980:1840.(3)ThompsonIE,Melia KM, :ChurchillLivingstone,1983:34-57.(4) :sociologyinhealthandmedicineLondon:Nuff ieldProvincialHospitalsTrust,1980:11-44. (5) ;3:113-130.(6) ;2:35-39.(7) ' ;28,1:63-72.(8)CulverCM, :OxfordUniversityPress,1982:49.(9) :WasserstromR, :WadsworthBelmont,1971:107-126.(10) , :JWileyandSons,1983:101-118.(11)Conducta ndUtilisationofResearchinNursing(CURN) :MichiganNurses'Association/GruneandStra tton,1982.(12) ;129:513-531.(continuedonpage135.)copyri ght. on April 9, 2022 by guest. Protected Med Ethics : first published as on 1 September 1986. Downloaded from Debate:Canpaternalismbemodernised? ,andespeciallythelatter,wouldseemnotonly questionablebutuntenabletomanyofus,thusw eakeningtheforceofWeiss' ,however'modernised'.

7 Medicalpaternalismisthedoctrine,first,th at'doctorknowsbest',notonlyabouttechnica landscientificmatters,butaboutwhatis'goo dfor'thepatient;and,secondly,thatthisjus tifiesthephysicianinmakingthepatient' ,bothbecausethequestionofwhatisgoodforor badforaparticularindividualisnotanobject ivequestion,butonetobedecidedonlybythein dividualhimselforherself; ,thenthephysician,nomatterhowfoolishhema ythinkthatdecision, , ,ratherthanthatmedicineexistsforthesakeo fpatients, 's'modernised' 'svaluesandinvolvingpatientsintheirowntr eatmentwhichseemtobethehallmarksofthismo dernisedpaternalismare,ifthisisgenuinepa ternalism,merelyasham,sinceitisstillthep hysicianwhomakestheultimatedecisionsabou tthepatient' ,iftheyarenotashambutagenuineconcessiont opatientautonomy, , 'sprogrammeofseminarsonmedicalethicsform edicalstudentsandforstudentsofpsychiatry , (1) ;11 'snoteAresponsefromDrWeisshasbeeninvited andisexpectedinduecourse.

8 (Seealsoarticlesbeginningpages127and131. )(continuedfrompage126)(13) ;11:184-187.(14) ;7:370-390.(15) ;288:216-219.(16) ;2 on April 9, 2022 by guest. Protected Med Ethics : first published as on 1 September 1986. Downloaded from