This paper analyzes and discusses the issue of human reproduction and ethics as this point applies to nursing in Canada. To begin with, we have to note that ethics is being added to the nursing curriculum in Canada up and down the land: an hour on anatomy, an hour on physiology, an hour on ethics, an hour on wound management, an hour on pressure sores, and so on. What purpose does this serve? What difference does or can it make? Will it change the way nurses think about their work? Will it change it fundamentally? Will it improve nursing, making it more decent, more humane?
The Encyclopedia of Bioethics (edited by Warren T. Reich) is an internationally reputed and leading bioethics reference text. The first edition of this work was published just over two decades ago in 1978 and stands as the first encyclopedia in the field. Developed with the support of the Kennedy Institute of Ethics at Georgetown University, Washington DC, the complete unabridged volumes of the encyclopedia gave the world at that time (and since) possibly one of the most comprehensive and valuable literature resources in contemporary moral philosophy.
Of significance to this discussion is that, in the introductory statements of the first edition, the encyclopedia claimed to have provided coverage of a broad range of issues in bioethics from an interdisciplinary, intercultural and international perspective. Despite this claim, it was evident that the encyclopedia had failed to do justice to the moral experiences of nurses and a nursing perspective on bioethics. A critical review of the reference revealed that it contained some omissions and biases that minimized and disadvantaged nursing’s position both within it (the text) and the field of bioethics it was advancing. In sum, nursing ethics was reduced, marginalized and to some extent invalidated in and by this impressive work.
In 1995, a new and substantively revised edition of the Encyclopedia of bioethics was released. This new version has corrected many of the omissions and biases contained in the first edition; the details are given shortly. Given the importance of the first edition, however, and its significance to the history and politics of nursing ethics and nursing ethics inquiry, an examination of its earlier omissions and biases is warranted.
As already stated, the first edition of the Encyclopedia of bioethics claimed to advance a compelling interdisciplinary, intercultural and international approach to the new field of bioethics. Nevertheless, despite its comprehensiveness and outstanding list of contributors, this early edition of the encyclopedia failed to do justice to a nursing perspective on bioethics. Examples of omissions and inadequacies can be found in the encyclopedia’s preface, list of editorial advisory board members, list of contributors, index to contents and appendix of ethical codes. The introduction states that several editors from some scholarly journals served both as advisory and critical reviewers of the encyclopedia project. Included are editors of scientific, theological, philosophical, psychological, medical, ethical and medical ethics journals. No nurse editors and no nursing journals are mentioned.
Ethics and nursing: Canadian perspective
Many ethics courses presuppose that nurses have a need for help with moral decision making and that to satisfy this requirement they should be taught ethical concepts or principles or even moral theory. It is assumed that nurses need yet another procedure, a framework of rules, which they can apply to the situations they encounter at work in Canada. It is curious how in many ways a lot of nursing ethics now taking shape on curricula imitates the technocratic and curative approach to health. As is generally recognized (often in the same documents which make a case for nursing ethics), instead of looking for and dealing with the conditions which give rise to illness, our health care system invites us to bombard the victim with the latest scientific wonder-radiation, chemicals, lasers, ultrasound, gene-carrying viruses or what you will-and very often makes matters worse (Elizabeth 2006).
In the case of human reproduction ethics, many appear convinced that a heavy dose of theories and principles carrying labels like deontology or utilitarianism, beneficence, non-maleficence, autonomy, quality or sanctity of life will fill the moral void in Canadian health care system. Surely everyone knows that student nurses do already have the responses of honesty, promise-keeping, respect for others, privacy, self-esteem and do understand these concepts. There is no reason to suppose teachers to be morally superior to students (Roy et al. 2006). The problem does not lie in some moral ignorance to be rectified with the latest in the right technology. Most people come to their health care workplace and put on their uniforms already equipped with everything human they need to treat the people in their care decently. The problem is that the circumstances and character of nursing do not allow them to do so. To shed one’s mufti and don a uniform is to be required to drop one’s moral sense and don the metaphysics of procedure.
Ethics in human reproduction in Canada
In human reproduction’s ethical discussion about nursing practice in Canada, it is not easy to steer clear of the temptation to start off by describing and analyzing moral concepts. One has to be careful to avoid any suggestion that the reason privacy is on the whole not well respected in health care institutions in Canada is that the health carers stand in need of a clear definition of privacy or dignity or person. All this is not to say that student nurses in Canada cannot benefit from a moral debate about health care matters and situations, and learn from instruction in professional ethics and the law. I take it for granted that the discussion is illuminating and the instruction useful (Process and Principles 2002).
What one has to beware of is making the problem appear to be one of finding the technically right procedure or method for dealing with ‘ethical decisions,’ as though the problem were similar to seeing the proper medication or the correct diagnosis or the right administrative rule. It diverts attention away from an inquiry into the concrete realities which make decent care difficult or impossible. Far from making the situation better, this technical-ethical approach makes it worse (Ross-Kerr et al. 2003).
Nurses in Canada need ethical exploration. That is, they need freely to examine from cases, preferably in their own experience, the conditions which create disparities between what their ordinary moral sense tells them and what they are expected to do without question, expected to accept, believe and justify without moral doubt or anxiety. Of course, it may be convenient to begin the discussion with a theme such as ‘confidentiality’ or ‘consent,’ but not along the line of ‘applying a principle’ which in practice turns out to be irrelevant or even oppressive (Moorhouse and Yeo 1996).
To work successfully in the health care system in Canada is to accept a metaphysics, and an ideology-to accept a way of working which has evolved over decades and is there waiting to receive one on its terms. If one does not take those words one is unlikely to be employed, and if one is employed then one may find oneself at best merely tolerated and at worst expelled. Nursing education in Canada has always been more than a piece of training in anatomy, physiology and nursing tasks-it has been an ideological preparation, even an indoctrination. The fear is that nursing ethics while hoping or pretending to break with the old, may be appropriated, may become part of that metaphysics of procedure (Process and Principles 2002).
Ethics in the field of human reproduction has made its appearance on the nursing agenda in Canada because of a crisis of legitimating in the health care of the Western world. People are losing confidence in the orthodoxy. Healthcare technocracy has reached a state of development at which, despite its achievements, its failings are manifest and its promises exposed as hollow at the same time that its power has become unbearably overweening-this is especially evident in North America.
Healthcare ethics is perhaps the system’s promise to clean up its act, and clean it up on its terms. The danger is that the professional under threat by a disenchanted public will soon, armed with a Masters degree in Health Care Ethics, claim a new expertize-moral expertise. Any other way of fielding questions from dissatisfied patients, clients, and their families? One may suspect that ‘ethics’ began where public accountability failed. The danger is that a democratic deficit is being filled with philosophical jargon. The question ‘Whose ethics?’ is fundamental.
Knowing your rights and following the code
Who defines it as a ‘field’ in the first place in Canada, who controls it, who benefits from it? It is natural perhaps to suppose that ‘ethics’ is something standing outside all the real world conflicts in the health care arena-as something which experts (mostly utilitarian and rationalist philosophers) have exclusive access to and can convey to the health care professional so that everyone will benefit (Roy et al. 2006). The health carer learns some moral theory, learns to speak in a mostly incomprehensible fashion and is supposed all the better for it, ready to apply her new-found ethics to the real world.
Still, things are not so bleak. One may instead apply the real world to ethics. Listening to people in care one may learn to approach ethics differently. The crisis of legitimating provides an opportunity for cultural renewal, for an ethics of resistance to stultifying biomedical bureaucracy. After all, is not the problem one of the conditions and constraints of the healthcare institution in which people work, constraints which often engender fear, paralysis and at worst a kind of blindness necessary to preserve the integrity of the self? If so, this suggests the need for what may be called a negative ethics, an ethics which, instead of trying to tell people what is right, allows them to discuss what is wrong, to investigate what it is that does not let them to do what is right or, sometimes, see what is right. It would be a critique of our health care practices by encouraging a self-discovery of the obstacles, of whatever kind, to acting in ways which we know to be right. I say this aware of the dangers of adopting some moral standpoint from which to indoctrinate students anew. I do not intend to promote any such perspective, but rather to facilitate the emergence of various viewpoints out of the honest and rigorous examination of issues posed by nurses and their teachers (Process and Principles 2002).
Conflicts between the modes of thought of ‘professionals’ and so-called ‘lay’ people, of nurses and doctors, of management and employees about health and health care need to be critically examined. Such a requirement is recognized at once by the neophyte nurse if sometimes accepted with greater reluctance by the nurse who has practiced for many years and has come to accept the norms of the institution. To undertake this kind of negative and exploratory ethics requires the opportunity and the freedom openly to tease out the inconsistencies in thinking about the nature of nursing and to seek their origin, to discuss the history and politics of nursing, its place in contemporary life and its relation to major social issues such as the environment and civil rights (Hogan and Roher 1989).
Such questions go beyond the notion of ethics as dealing with proper conduct, malpractice, and negligence. Here is a noble endeavor which challenges standard practice, which recognizes that even where everything is following set rules and procedures, and no one can be blamed for any wrongdoing, still something may be radically wrong. Honesty, for example, is an ethical imperative which goes far beyond matters such as the wrongness of stealing patients’ property or drugs from the medicines’ cabinet. Those questions of professional honesty (which are not without their importance, of course) leave quite untouched the deeper issue of whether our perceptions, justifications, and reasoning about illness and disease and our remedies for them are dishonest, an illusion serving narrow interests. Thus the obstetrician may be perfectly honest and conduct himself ‘ethically’ as a professional in emphasizing ‘risks’ and ‘abnormality’ and bring the expectant mother under his control where she may be ‘monitored.’ But what if this control is unnecessary? What if, as the evidence strongly suggests, home births are safer than hospital births? What if monitoring has unacknowledged dangers? What if the mother finds the hospital delivery upsetting or even humiliating? The ethical question then moves to a deeper level is it a misconception that contemporary obstetric care is good and right? (Hogan and Roher 1989)
Code of Ethics explained
A general criticism put against codes of conduct is that they are the un-argued presentation of the dos and don’ts of the profession (Process and Principles 2002). They lack any coherent underpinning regarding normative ethics, and as such amount to the reification of a more or less arbitrary series of moral intuitions. It may be illustrated by reference to the paragraph of the Canada’s Nursing Code that requires the practitioner to recognize and respect the uniqueness and dignity of each patient and client, and respond to their need for care, irrespective of their ethnic origin, religious beliefs (Hogan and Roher 1989). While such a principle is important, it provides no guidance as to how conflicts between professional views and the client’s beliefs are to be resolved.
While an ethics of respect may be defended, the extreme suggested by Harris, such that the autonomy of patients involves the ‘freedom to make irrational or capricious choices, if that is what [they wish] to do’ makes no allowance for beliefs that may entail law breaking (such as the desire for active euthanasia) or beliefs that, if realized as actions, would harm others. However, the purpose of this paper is not to defend the development of coherent normative ethics to underpin such codes in Canada. It is rather to recognize and assess the effective grounding that the codes already have in the practitioners’ informal beliefs.
This analysis can be developed by noting that any practice-governing rule is necessarily incomplete in itself. Its precise application to a given situation, and hence its meaning, must be governed by an infinite series of additional regulations. As Wieder has noted, the interpretation of an utterance depends upon,
(a) who was saying it…; (b) to whom it was being said…; (c) where it was being reported…; (d) on what kind of occasion it was being said…; (e) the social relationship between teller and hearer…; and so forth (Devine and Cook 1993).
While a Canadian code of conduct is designed to be applicable to a more diffuse set of social situations than, say, an utterance made in face-to-face conversation, assumptions about the authors of the code, the audience, the power relationship between the two, and so forth, will be implicit in any interpretation of the system. The description of a rule-governing principle, and hence the repair of its indexical nature, will rest upon the lifeworld presupposed by the interpreter. The problem of interpreting and applying a principle from a code of conduct is resolved by (more or less unreflective) appeal to specific competencies held by the professional. The competent social actor will have the skill, when confronted by a novel situation, to relate it to particular known, and unproblematic, types, and thus if relevant, to the code. It may be illustrated in more detail (Moorhouse and Yeo 1996).
The main principles of a code tend to be so general as to become trivial. Its annotations partially repair the indexical nature of the system. The Royal Pharmaceutical Society’s code’s paragraph 1 may illustrate this: ‘A pharmacist’s prime concern shall be for the welfare of both patients and public.’ The annotations to this principle list a series of situations that may provide problems to the pharmacist, and of which the code serves to make them aware. These include the sale of slimming and other non-medical products, the sale of chemicals, and sales by post. Such annotations amount to a catalog of the problems that have confronted pharmacists, and for which they may be expected to take responsibility. The professional is being warned not to take certain situations for granted. It may then be suggested that in the repairing of the indexicality of code the presupposition of a coherent normative ethics is of less (or indeed of no) importance in comparison with the collective practical experience of the profession (Roy et al. 2006).
The most fundamental question for anyone considering ethical practice in nursing in Canada is whether such a thing is possible. Particular ethical concerns arise where there is responsibility, and responsibility presupposes freedom. It is still far from clear whether nurses in Canada are free to judge and act as carers-and scrutiny of this leads one to fall back on the more profound question of what a nurse is. Even in Canada, where nursing is said to be more independent of medicine, the root question is still how far it is sovereign and in what ways?
Even to raise the question of nursing independence is still entirely novel, undoubtedly unorthodox and perhaps revolutionary. The subordinate nature of nursing was established in the last century. The growth of scientific medicine and its development in hospitals created a need for doctors to have assistants who would do their bidding and keep the place in order. The Nurses, Midwives and Health Visitors Act 1979 was regarded by some as the herald of a new era of professional nursing, a kind of liberation.
The subordinate role of nursing is also unquestionably tied up with the subservient role of women generally, for it is still true that the overwhelming majority of nurses are women while the vast majority of those who give them instructions (doctors, managers) are men. Thus the fundamental ethical question of nursing-its moral freedom-is also the ethical issue of gender.
The talk of accountability in nursing which began with the 1979 Act has intensified of late. Managers, particularly nurse managers, speak of it frequently, nurse educators give classes with this theme and professional bodies re-emphasize its importance. The average nurse still appears to believe that accountability is all about the following procedure and making sure that ‘one is covered’ by having the right kind of note or record or witness to refer to when something goes wrong or when, for whatever reason, an accusation is made. Still, one does hear from many that there is more to it than this-but what? What does ‘accountability’ mean? What is at the bottom of all this talk? It is the question which I shall address here, in very general terms.
Talk of accountability arises with the fundamental transformation which nursing is undergoing in Canada and the US. The change that it is undergoing may not be the same officially claimed. In fact, it is still too early to say definitely what kind of transformation this is, except that it already appears that the age-old gap between nursing ideas and practice is taking yet another form. On the one hand, it would look that ‘accountability’ is about the liberation of nurses, about a new freedom, responsibility, and professionalism. On the other, the evidence is of ‘accountability’ functioning as the central idea in a new ideology of disciplined accommodation to structural changes required by a quasi-market in public healthcare provision. There is a widespread ambivalence in the use of the term. Put a cross-section of the healthcare hierarchy around a table and very often you will find them disagreeing about almost everything, only finally to agree about the importance of accountability. It appears that there is a concept serving an ideological function, one which papers over profound conflicts of interest. In a reversal of the story about blindfolded people feeling an elephant, all of whom come up with different ideas about the object before them; here everyone thinks they have an elephant when they are touching entirely different animals.
Demanding ‘accountability’ does not in itself say anything about whom one is accountable to, or who has the right to hold one to account. It neither says what things one is, or ought to be, responsible for, nor what the limit to these things is. It does not mean by what criteria, or on what basis, one is held to account. There will be many contexts in which demands for accountability come into conflict with one another. And it is often important to distinguish between the responsibility of an individual and that of a group or institution.
One suspects that the recent talk of accountability is, for the most part, an absorption of nursing into a more thoroughly technical-rational understanding of health and healthcare. 6 Hence the increasing employment of administrative techniques and instruments such as QALYs (Quality Adjusted Life-Years), Audit, Quality Assurance and other measuring devices in understanding needs, delivery and distribution. Accountability is here tied up with the increasing technicalization of care.
However, if a principle is necessarily incomplete, then so too are its annotations. While the above example indicates the importance of annotations (and a weakness of Canada’s Code is the lack of a comprehensive set of annotations, or even readily accessible ‘case law’ as to the principles’ application), ultimately appeal must be made to the informal rules acknowledged within the profession, and within everyday social practice.
The pharmacist should refuse sales if there is a reason to believe such products are being misused (Ross-Kerr et al. 2003). It rests upon two presuppositions. First, there is no explanation of why such use of laxatives is ‘misuse.’ That the statement is obvious demonstrates the appeal to a taken-for-granted set of beliefs that is part of the substantive life world of most (but by no means all) members of contemporary British society. Second, no further criteria are given by which such misuse could be judged at the point of purchase. Again, any attempt to explicate such standards, being beyond simple quantification, would be in vain. The skills of the pharmacist as a competent member of society will, in general, be adequate to the task.
I have argued that the interpretation of a code of conduct depends upon certain presuppositions current within the profession, and indeed outside of it. The precise formulation and wording of code are of significance. There are extreme cases (as noted with a police force) in which the professional life world will lead to the ‘ironisation’ of the code, such that its tenets become meaningless. Even in these cases, the existence of the code, and its non-ironic interpretation by those outside the profession are important. Such non-ironic interpretation, on the one hand, works to legitimate the legal monopoly of the profession, but on the other hand, may be used to make professionals accountable to external, and more exacting, standards of morality. The code is a participant in any process of interpretation. If the members of the profession take the code literally, which may be regarded as typical in the ‘caring’ professions, then precise wording may encourage certain responses and forestall others. The Canadian and American social work codes, on numerous points, provide models for such formulations. In the case of the Canadian Code of Ethics for Registered Nurses, the Code bears too many of the hallmarks of codes typical of conservative professions. The lack of adequate annotation, and too active undermining of the pre-professional competencies of its practitioners, including political competences, mean that the Council’s interpretation of the Code must go largely unchallenged. The Code works merely to reinforce that which is already accepted, or that the Council wishes to see approved, in the professional life world. The Code, it seems, is there to be taken for granted. It may tend to the unchallenged reproduction of the hierarchy within the profession, for good or ill, and insulate the job from a critical resource, thereby paradoxically hindering the process of professionalism. While the sincerity of the Code is not to be doubted, the rigor with which it examines the professional lifeworld, and more importantly the degree to which it makes possible the problems revision and following revision of that lifeworld are questionable. It may be suggested that a profession that is denied its actual status and resources should have a code that welcomes open debate and engagement, internally and externally.
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