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1 WHAT DO WE MEAN BY ETHICS?
The aim of this unit is to give the reader an understanding of ethics, and an awareness of how fundamental ethical principles and our personal values and beliefs contribute to our way of thinking in making ethical decisions.
AIMS
By the end of this unit you should be able to: .
Define the term Ethics.
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Have explored personal beliefs, attitudes, and values.
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Have an understanding of the delicate balance that exists between principles, and personal values when making decisions of an ethical nature.
OBJECTIVES
The required reading for this unit is as follows: Basford L., Slevin O.D. (eds.) 1995 Theory and Practice of Nursing: An Integrated Approach. pp. 59-63, pp. 141-166 Edinburgh: Campion Press.
REQUIRED READING
Thompson I., Melia K., Boyd K. 1994 Nursing Ethics Chapter 1 Edinburgh: Churchill Livingstone (3rd. Ed.)
This unit will be an exploration of ethics and moral choices, and of the values and principles that lie behind them. Various definitions of ethics will be examined with the view to enabling the reader to reflect and choose the definition they think most adequately reflects the subject area of ethics. The readings will be introspected with activities enabling opportunity for personal reflection and discussion with colleagues.
Unit 1: What do we mean by Ethics?
INTRODUCTION
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Everyone is interested in ethics. Before becoming immersed in ethics as they apply in health care it may be beneficial to spend a short time discussing ethics at a general level.
DEFINITION OF ETHICS
Ethics as a discipline is a branch of moral philosophy and many use the terms morality and ethics interchangeably. Some of the concerns of moral philosophy are questions such as: . . .
‘What is the Good Life?’ ‘How should I live?’ ‘How should I treat other people?’
The starting point of ethics is also an examination of these questions, but not purely at an abstract theoretical level. Ethic’s emphasis is on action and its concerns centre mainly on whether our actions and their consequences are right or wrong. A broad general definition of ethics is that it is concerned with doing good and avoiding harm. Kirby and Slevin define it as follows in Theory and Practice of Nursing (p. 143): ‘Ethics is the study of moral thinking, the values we attach to thoughts or actions; it is also the study of how we determine what we ought to do and what we actually do when we make moral choices.’ A more specific definition of ethics taken from the work of philosopher Teresa Iglesias, (whose specialist area is health care ethics) in In Vitro Fertilisation and Justice (p. 16) is as follows: (Ethics is) ‘the systematic study of general principles which govern mans (womans sic) life’. Already we can see that there is a different emphasis between these two definitions of ethics. The definition taken from Kirby and Slevin is concerned with the values we give to our thoughts and actions, and how we decide to make a moral choice, and what we actually do when the decision is made. It would appear that this is somewhat a general definition, while on the other hand Iglesias’s definition is introducing a very definite tone using terms such as ‘systematic’ and ‘principles’. We may ask the question, what are principles and where do they originate from? Principles are starting points metaphorically speaking, that govern our behaviour as human beings living in the world with other human beings. In order to live in a civilised and peaceful manner as a society, certain principles, or rules must exist in order to ensure peaceful co-existence, with one’s fellow human beings. An example of a general principle dating back to the 7th. century B.C. ‘Do unto others as you would have done unto you’
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Professional Issues in Nursing: Section C - Ethical Issues
Hippocrates, the father of medicine, who lived around 460 B.C., formulated the principle upon which medicine and also nursing is founded on ‘Do not cause harm or injustice to another human being, do him (her sic) good’. Today, with advances in health care and medical technology, the principle of not causing harm to the patient has become a difficult principle to adhere to at all times. This is a point we shall be constantly returning to as this unit progresses.
SAQ 1 Spend time reflecting on the above definitions in conjunction with the readings recommended, and choose a definition of ethics that you think reflects clearly and succinctly the subject matter. You must be able to justify your choice.
In addition to principles, one’s ethical behaviour is also influenced by one’s values and personal beliefs. These values and personal beliefs are attitudes and dispositions we imbue from our culture, religion and family. Generally speaking, beliefs are based more on faith than fact. They are, however, powerful motivating forces determining what action we take. These beliefs form our attitudes about ourselves and other people, e.g. if we believe that people are basically honest then one would be open with others and promote honesty.
AN EXPLORATION OF PERSONAL BELIEFS, ATTITUDES, AND VALUES
Values are less fixed and more dynamic. Again they are shaped by one’s upbringing and society - they are however more subject to change as can happen when one experiences a midlife crisis. Our values, attitudes and personal beliefs play a central part in our ethical decision making process, and it is of vital importance that we are self aware in this regard. When one is aware of one’s own values and beliefs, one is more accepting of and able to live with other people’s viewpoints, and not to expect them to conform to our way of thinking. In health care one encounters others who may have differing value and belief systems, or may come from a different culture, and so it is an essential attribute of nurses to be able to have an appreciation and understanding of these differences when caring for others. An example of differing values and beliefs posing an ethical dilemma in health care, would be a situation where a person who is a Jehovahs Witness, is admitted for surgery, but refuses to have blood transfusions if they are required. This scenario poses an ethical dilemma for the health care team involved who would profess a duty to care, and to do good. Of course a Jehovahs Witness who is of sound mind is perfectly entitled to stipulate that he or she does not want a blood transfusion, even if this action will put their life at risk, but some members of the health care team may disagree with their decision.
Unit 1: What do we mean by Ethics?
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SAQ 2 Take time with a colleague to explore personal values and beliefs. You could use the above example to explore how you would feel if you were a nurse caring for the above patient, and imagining that the scenario is one of an negative outcome.
In making a decision about whether an action is right or wrong, in health care one considers both principles or rules and also one’s personal values and beliefs. A purely rule based approach to ethical decision making would be somewhat impoverished and excludes the personal and existential aspects of a situation. Existential means appreciating the other persons situation and also being aware that we must all work out in as far as it is humanly possible the right thing to do in any given situation of an ethical nature. We must, as Verena Tschudin says in Deciding Ethically ask the question ‘What is happening?’. In other words we must always be aware that every case and situation is unique to that person, and by virtue of this we must all think about our ethical behaviour and live and act according to our individual consciences. This involves thinking and working through our received beliefs and values and making individual choices, as conscientious people.
BALANCING ETHICAL PRINCIPLES WITH PERSONAL BELIEFS AND VALUES
Socrates, a philosopher and secular prophet who lived in the 5th century B.C. devoted his life and work to the task of stinging people into existence. Socrates viewed his role as that of a ‘gadfly’ sitting on the back of Athens, attempting to sting people into existence. His constant theme was the questioning of conventional morality. He is famous for his maxim ‘Know Thyself’ and in tandem with this he believed that ‘The unexamined life is not worth living’. In other words we must be self aware, always question and work things out for ourselves, and not make decisions based purely on conventional values and customs. Socrates believed that by the use of reason, one could arrive at a set of principles, which would serve self interest with the common good, and thus apply to all people at all times. He took his duty of examining and questioning beliefs, so seriously that he died for these beliefs and principles. Socrates is written about by his pupil the famous philosopher Plato in The Last Days of Socrates. The main point I would like you to take from this section is an awareness that all of us are individuals endowed with reason and individual consciences. We all have an ability to work out for ourselves what the right action is in any given circumstance. For nurses working within the constraints of institutional settings one’s individual conscience can on occasions embroil one in a situation of ethical distress. A well documented incident of this nature in the nursing world was the case of Graham Pink, a British nurse who became known as the whistle blower in the NHS Nursing Times (1992) Vol. 88 No. 24.
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Professional Issues in Nursing: Section C - Ethical Issues
Graham Pink, who worked at Stepping Hill Hospital Stockport, was concerned with the low level of staffing available in caring for acutely ill geriatric patients. He wrote letters of complaint, firstly to his managers, and when he received no affirmative action he ended up in desperation writing to the then prime minister Mrs. Thatcher and the press. In trying to bring attention to the plight of his patients he unfortunately wrote about them in a manner that enabled them to be identified. As a result of this, the hospital dismissed him on grounds of breaching confidentiality. This case is a good example of a situation involving ethical distress or outrage, where institutional values and policies were given precedence over an individuals notion of what is the right and good action.
SAQ 3 Discuss the above case with a colleague and try to envisage what your response would be if you found yourself in a similar situation.
In this unit you have explored ethics at a general level. You have reflected on the subject matter pertaining to ethics and morality, and chosen a definition you think adequately reflects the subject, and given the reasons why you choose that particular definition.
REVIEW
An awareness of principles or rules was introduced, and this approach was balanced with self reflection on personal values and beliefs. The concluding unit incorporated the individual as a person of moral integrity and ultimately the decision maker when considering an action of an ethical nature. Nursing as a practice discipline is primarily focused on action, and concerned with doing good for the patient and avoiding harm to the patient, so we can say that nursing is by its nature ethical, that is concerned with doing good. Ethics is a fundamental tenet of the profession as all actions either directly or indirectly involve some ethical decision making. However you may now be realising that unlike other areas of nursing when discussing ethics there are very few black and white answers, but a very broad area of grey. The single most important point to remember is that every case is individual and context dependant, and by virtue of this each case must be assessed individually.
Unit 1: What do we mean by Ethics?
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If you would like to read further about the issues in this unit, I would recommend reading some of the following:
ADDITIONAL READING
Nursing Times 1992 Vol. 88 No. 24. The Indomitable Mr Pink pp. 26-31. Plato The Last Days of Socrates Penguin Books.
Iglesias, Teresa 1990 IVF and Justice London: The Linacre Centre. Tschudin, Verena 1994 Deciding Ethically London: Bailliere Tindall
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REFERENCES
Professional Issues in Nursing: Section C - Ethical Issues
SAQ 1
ANSWERS TO SAQS
Q. Spend time reflecting on the above definitions in conjunction with the readings recommended, and choose a definition of ethics that you think reflects clearly and succinctly the subject matter. There is no right or wrong answer. The choice is entirely yours. The only criteria I impose is that you must be able to justify your choice, in a rational coherent manner.
SAQ 2 Q. Take time with a colleague to explore personal values and beliefs. You were asked to discuss a hypothetical case study pertaining to a Jehovah’s Witness who refuses blood transfusions. Again this very difficult scenario was offered in order for you to explore your own personal beliefs and values as a nurse. The answer of course is that one would respect the patients autonomy at the expense of personal and professional values.
SAQ 3 Q. Discuss the Graham Pink case with a colleague and try to envisage what your response would be if you found yourself in a similar situation. I presented you with an ethical dilemma similar to the Mr. Pink case. I do not know what decision you decided to take but again you must be able to justify your action.
Unit 1: What do we mean by Ethics?
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